[Senate Hearing 117-947]
[From the U.S. Government Publishing Office]
S. Hrg. 117-947
THE HEALTH EFFECTS OF EXPOSURE TO AIR-
BORNE HAZARDS, INCLUDING TOXIC FUMES
FROM BURN PITS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON
PERSONNEL
OF THE
COMMITTEE ON ARMED SERVICES
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
SECOND SESSION
__________
MARCH 16, 2022
__________
Printed for the use of the Committee on Armed Services
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
59-663 PDF WASHINGTON : 2025
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COMMITTEE ON ARMED SERVICES
JACK REED, Rhode Island, Chairman JAMES M. INHOFE, Oklahoma
JEANNE SHAHEEN, New Hampshire ROGER F. WICKER, Mississippi
KIRSTEN E. GILLIBRAND, New York DEB FISCHER, Nebraska
RICHARD BLUMENTHAL, Connecticut TOM COTTON, Arkansas
MAZIE K. HIRONO, Hawaii MIKE ROUNDS, South Dakota
TIM KAINE, Virginia JONI ERNST, Iowa
ANGUS S. KING, Jr., Maine THOM TILLIS, North Carolina
ELIZABETH WARREN, Massachusetts DAN SULLIVAN, Alaska
GARY C. PETERS, Michigan KEVIN CRAMER, North Dakota
JOE MANCHIN III, West Virginia RICK SCOTT, Florida
TAMMY DUCKWORTH, Illinois MARSHA BLACKBURN, Tennessee
JACKY ROSEN, Nevada JOSH HAWLEY, Missouri
MARK KELLY, Arizona TOMMY TUBERVILLE, Alabama
Elizabeth L. King, Staff Director
John D. Wason, Minority Staff director
_________________________________________________________________
Subcommittee on Personnel
KIRSTEN E. GILLIBRAND, New York,
Chair THOM TILLIS, North Carolina
MAZIE K. HIRONO, Hawaii JOSH HAWLEY, Missouri
ELIZABETH WARREN, Massachusetts TOMMY TUBERVILLE, Alabama
(ii)
C O N T E N T S
_________________________________________________________________
march 16, 2022
Page
The Health Effects of Exposure to Airborne Hazards, Including 1
Toxic Fumes From Burn Pits.
Member Statements
Statement of Senator Kirsten Gillibrand.......................... 1
Statement of Senator Thom Tillis................................. 2
Witness Statements
Rauch, Terry, PhD, Acting Deputy Assistant Secretary of Defense 3
for Health Readiness Policy and Oversight.
Szema, Anthony, Medicare, Director, International Center of 16
Excellence in Deployment Health and Geosciences, Northwell
Health Foundation.
Porter, Tom, Executive Vice President, Government Affairs, Iraq 19
and Afghanistan Veterans of America.
Torres, Rosie, Executive Director, Burn Pits 360................. 23
Patterson, Steven, Former Environmental Science Officer, Combined 30
Joint Task Force 101 Headquarters, Afghanistan, 2008-2009.
Questions for the Record......................................... 40
Appendix
Supporting documents for Colonel Adam J. Newell question #10..... 51
Supporting documents for Dr. Terry Rauch question #27............ 61
(iii)
THE HEALTH EFFECTS OF EXPOSURE TO AIRBORNE HAZARDS, INCLUDING TOXIC
FUMES FROM BURN PITS
----------
WEDNESDAY, MARCH 16, 2022
United States Senate,
Subcommittee Personnel,
Committee on Armed Services,
Washington, DC.
The Committee met, pursuant to notice, at 3:30 p.m. in room
SR-232A, Russell Senate Office Building, Senator Kirsten
Gillibrand (Chairman of the Subcommittee) presiding.
Committee Members present: Gillibrand, Warren, Hirono,
Tillis, Hawley, and Tuberville.
OPENING STATEMENT OF SENATOR KIRSTEN GILLIBRAND
Senator Gillibrand. Good afternoon, everybody. The
Personnel Subcommittee meets today to receive testimony on the
health effects of exposure to airborne hazards, including toxic
fumes from burn pits. Let me start by welcoming Ranking Member
Tillis, who will be here very shortly, who has been an
excellent partner on this subcommittee over the last several
years. Senator Tillis and I have shared a commitment to
supporting our servicemembers and providing them with the
services, resources, and care that they need.
That commitment extends to our shared drive to address the
debilitating and extensive medical issues and disabilities
caused by the use of burn pits in recent combat operations.
When our servicemembers deploy they expect to face risks, but
those risks should not come from the operations of our own
bases, and when they do, we must take responsibility. I look
forward to continuing to work together on this issue.
I was also glad to hear that President Biden prioritized
addressing this cost of war in the State of the Union, and
again in Texas last week. He described the clear cause and
effect of this crisis saying, ``The burn pits that incinerate
the waste of war, medical and hazardous material, jet fuel, and
so much more were just dug in big pits, not far from where our
veterans were sleeping, and when our troops came home, the
fittest among them, the greatest fighting force in the history
of the world, too many of them were not the same--headaches,
numbness, dizziness, cancer.'' That tells the whole story. Men
and women who deployed at the peak of physical fitness are now
fighting to survive.
This is a health crisis among our armed services. Most
public attention on this issue has been focused on the
treatment of veterans at the Veterans Administration, but these
health issues stem from time on Active Duty and can begin
presenting while our troops are still serving. The DOD
[Department of Defense] has a critical role to play in
protecting the health of our current and transitioning
servicemembers. That is why today's hearing is so critical. We
need to have a better understanding of how toxic exposure has
been and is being tracked and documented, and the barriers that
have presented that documentation from being done effectively.
Congress has already recognized DOD's responsibility and
has passed legislation to require DOD to take appropriate
measures, including requiring inclusion of exposure to open
burn pits in post-deployment health assessments of
servicemembers returning from deployment, recording burn pit
registration in electronic health records, and mandatory
training for military health care providers on the effects of
burn pit exposure.
But we need to go further. We need to build an
understanding of the health impacts of toxic exposure and our
knowledge of when such exposure is occurring, and we must make
that information available to servicemembers, their families,
and the medical professionals they rely on in order to properly
and adequately care for our troops who have been exposed.
As President Biden said, quote, ``We need to know more
about which of our veterans may have been exposed to burn pits
in the first place or other environmental toxins during their
service, and record possible exposure before servicemembers
separate from the military,'' end quote.
Today's witnesses will help provide clarity in both of
those areas. Our first panel consists of DOD witnesses who will
testify about the health effects of toxic exposure, assessment
of health impacts, documentation of potential exposure, and
monitoring of exposure. Witnesses on our second panel will
share what they have seen or experienced firsthand on this
issue and will provide recommendations for ensuring the health
and safety of our servicemembers.
Witnesses for our first panel include Dr. Terry M. Rauch,
Acting Deputy Assistant Secretary of Defense for Health
Readiness Policy and Oversight; Dr. Raul Mirza, Division Chief
of Occupational and Environmental Medicine, Clinical Public
Health, and Epidemiology, U.S. Army Public Health Center;
Colonel Adam J. Newell, Chief of Medical Readiness, Air Force
Medical Readiness Agency; and Captain Brian L. Feldman,
Commander, Navy and Marine Corps Public Health Center.
I will introduce the second panel after we receive the
testimony of the first panel. Again, thank you for being here
today, and just for Senator Tillis' benefit, I told him how
wonderful you are at the opening of my remarks.
STATEMENT OF SENATOR THOM TILLIS
Senator Tillis. Could you please repeat that? I am sorry I
am running late. I went ahead and voted so I figured we could
tag team and not disrupt the hearing. But thank you all for
being here. Senator Gillibrand, thank you for holding the
hearing and your advocacy of the work that I am well of in
veterans' affairs, that we need to continue to work on.
I have worked on this subject for a long time when I first
came to the Senate. I was involved with trying to get the
presumptions in place for Camp Lejeune, toxic exposures down
there. Fortunately, after a lot of back and forth with the
Veterans Affairs (VA) we were successful, but we have more work
to do.
I am happy that the Veterans Affairs Committee has
unanimously reported out a bill on toxic substances. We are
going to continue to work in the VA Committee to do right by
those who were exposed and who are now in veteran status.
The objective of today's hearing, though--and it is
something that I have said on a number of fronts, whether it is
traumatic brain injury, low-level concussive events, things
that men and women, while they are on Active status, experience
that could ultimately result in problems in the long term--I
think we have an opportunity here to get ahead of it. Instead
of waiting for the next burn pit, or waiting for the next Agent
Orange, what more can we do downrange? What more can we do in
our military installations to understand the potential risk
that we are putting our men and women, potentially putting them
in a position to where they too are going to have negative
health consequences, either while they are serving or after
they transition to veteran status.
So today I look forward to talking with you all about how
we can get ahead of the curve, how we can do a better job of
tracking potential exposures so that it makes it very easy
later on, if we get into a situation. We cannot always, when we
are downrange, know what we are going to get exposed to, but
once we know it then we should make sure that every single
electronic health record of any man or woman who is exposed to
it is updated, and maybe we can even anticipate that they are
at risk before they ever exhibit the first symptom. That is the
end goal, and I am sure that you all, the witnesses, agree that
that should be an end goal of everybody.
So I look forward to this testimony today. I look forward
to moving up in the cycle, talking with the DOD to figure out
what more we can do to actually begin to bend the curve on some
of the consequences that we have to deal with, with our men and
women in uniform, and with the men and women who have served
before.
So thank you all. I look forward to your testimony.
Senator Gillibrand. Colonel Newell? Dr. Rauch?
STATEMENT OF TERRY RAUCH, PhD, ACTING DEPUTY ASSISTANT
SECRETARY OF DEFENSE FOR HEALTH READINESS POLICY AND OVERSIGHT
Dr. Rauch. Chairwoman Gillibrand, Ranking Member Tillis,
and members of the subcommittee, thank you for inviting the
Department to testify for the Senate Armed Services Committee
hearing on military exposures of concern, including airborne
hazards and open burn pits. I am pleased to represent the
Office of the Secretary of Defense and have the opportunity to
discuss the Department's actions in addressing airborne
contaminants and open burn pits in military options, and the
potential health effects to our servicemembers and veterans.
Joining me today and representing their military
departments are Colonel Newell from the Air Force, Dr. Mirza
from the Army, and Captain Feldman from the Navy.
The Department recognizes the concerns about the potential
health impact of burn pits and other airborne exposures. The
relationship between burn pit exposure and illness is a topic
of active research by the Department, the Veterans Affairs,
National Academies of Science, Engineering, and Medicine, and
other research institutions. The Department and VA continue to
support and fund these research efforts to better understand
any health effects that will better inform the health care
provided to our servicemembers and veterans.
Health care providers play a critical role in understanding
health-related exposures and becoming proficient in assessing
patients' exposure concerns. This month, the Department will
launch an updated version of its Airborne Hazards and Open Burn
Pit Registry Overview course for health care providers. In
addition to the training course, an Airborne Exposure Clinical
Toolbox is available to our health care providers.
The Department and the VA continue to share education,
training, and outreach products to improve exposure-related
clinical care. Airborne hazards pose potential acute and
chronic health effects during deployment and post-deployment.
As such, the Department has enhanced its pre- and post-
deployment-related health assessments and the Separation Health
Assessment to include more specific occupational and
environmental exposure questions, including questions on burn
pits and other airborne hazards.
The Department and VA are currently collaborating on
multiple efforts, including the development of the first-ever
Individual Longitudinal Exposure Record--we call it the ILER--
providing exposure summaries by leveraging personnel location,
environmental monitoring and health assessment data. The
Department is also conducting a comprehensive exposure
monitoring capabilities-based assessment aimed at improving
individual and area exposure monitoring and record-keeping
across the installation, training, and deployed environments.
In closing, the Department remains committed to continually
improving our understanding of exposures of concern and
potential health effects in order to prevent and mitigate
exposures and clinically assess, treat, and care for our
servicemembers and veterans.
Madam Chairwoman, that concludes my opening remark, and we
stand ready to address your questions.
[The joint prepared statement of Dr. Terry M. Rauch, Dr.
Raul Mirza, Colonel Adam J. Newell, and Captain Brian L.
Feldman follows:]
Joint Prepared Statement by Dr. Terry M. Rauch, Dr. Raul Mirza, Colonel
Adam J. Newell, and Captain Brian L. Feldman
I thank Chair Gillibrand, Ranking Member Tillis and the Members of
the Personnel Subcommittee of the Senate Armed Services Committee for
the opportunity to participate in today's hearing.
My name is Dr. Anthony Szema, Clinical Associate Professor of
Medicine (Divisions of Pulmonary/Critical Care and Allergy/Immunology),
and Clinical Associate Professor of Occupational Medicine, Epidemiology
and Prevention at the Donald and Barbara Zucker School of Medicine at
Hofstra/Northwell where I am Director, International Center of
Excellence in Deployment Health and Medical Geosciences. At Stony Brook
University, as adjunct faculty, I am Research Assistant Professor,
Department of Technology and Society, College of Engineering and
Applied Sciences.
Between 1998 and 2015 I was Allergy Section Chief, Veterans Affairs
Medical Center, Northport, NY. My expertise on this issue stems from
the following: my team first reported new onset asthma from Iraq and
Afghanistan Deployments among burn pit exposed soldiers in 2007,
described deployment related rhinitis in 2008, coined the term Iraq
Afghanistan War Lung Injury (IAW-LI) in 2011, based on lung function
testing data, developed animal models with burn pit base dust in 2014,
tested candidate drugs in mice in 2018, and co-invented new candidate
medicines this year.
I agreed to testify because, as a physician, I care about the
health and well being of my patients who are our soldiers.
The team in my office sees numerous patients post deployment with a
variety of symptoms which include shortness of breath, cough, and chest
tightness that is accentuated with exercise. I have diagnosed post burn
pit exposed soldiers with asthma, chronic obstructive pulmonary
disease, lung fibrosis, carbonaceous lung, constrictive bronchiolitis,
titanium lung, bladder cancer as well as pulmonary ossification or bone
in the lung. These are previously healthy, non-smoking, fit for
deployment soldiers who have newly acquired lung disorders after their
tours of duty. In one severe case, for example, my patient with lung
fibrosis required two lung transplants and died last December.
As an expert in the field, I have concluded that these lung
disorders are directly related to exposure to airborne hazards. These
ailments resulted from inhalational exposures to: burn pits, dust
storms, improvised explosive devices, as well as blast overpressure
from mortar fired rounds.
My conclusions are based on our analyses of lung biopsies
containing particles from these soldiers' lungs. These particles were
subsequently processed at two different sites with two different types
of technical machinery for analysis.
1) Center for Extraplanetary Exploration, Rahman Spectroscopy,
Department of Geosciences, Stony Brook University
2) Brookhaven National Laboratory, National Synchrotron Light
Source II Beam ID-5.
Analyses from both laboratories conclude that the particles from
soldiers' lung biopsies sustained exposure to high combustion
temperatures consistent with burning. Chemicals identified included
polycyclic aromatic hydrocarbons (PAH), and metals such as titanium and
iron. These metals were bound together. These metals were also
oxidized--which is evidence they were burned.
As doctors treating these patients, one challenge we face is that
there is inadequate screening for those military personnel who are
predisposed to lung injury. Lack of screening is a challenge for
diagnosing and treating patients for several reasons. First, if
individuals are not screened, then they may never get correctly
diagnosed. In addition, if they are not screened, and therefore not
treated properly, by the time they present to the doctor, the disease
is already severe and therefore, more difficult to treat.
The dilemma with military personnel, who typically do not have
asthma, since it is an exclusion diagnosis for enlistment, who must
pass basic training outdoors, and who must be fit for deployment at
Fort Hood prior to deployment, is that they usually do not have pre-
deployment pulmonary assessments.
Unlike the Fire Department of New York which requires annual
spirometry breathing tests and was able to assess respiratory changes
after 9/11, soldiers most often do not have a baseline for comparison
other than their 2-mile run time. An otherwise healthy young soldier
may be 100 percent or more predicted on spirometry and oxygen
consumption from a cardiopulmonary exercise test predeployment. So,
reduction to 80 percent predicted post-deployment is a significant
decrease even though 80 percent is the cutoff for normal.
Another challenge we face as the doctors treating these
servicemembers is the lack of information we receive. Without knowing
what they were exposed, or potentially exposed, to, it is hard to prove
what caused the ailment. For example, in one recent case last month, a
military firefighter, a patient of mine, was unable to get a referral
to the East Orange WRIIC. The primary care doctor in the local VA did
not believe that the military firefighter's sleep apnea, sinusitis,
asthma, and rhinitis were related to deployment, even though he had a
positive sleep study during his Active Duty.
Even if it is known that there were toxic materials at a certain
site, too often, soldiers visit our academic center without complete
documentation of locations of their deployment so their direct exposure
cannot be proven. This is especially the case if they were at forward
operating bases or places like Camp Stryker whose exact location is not
on the map.
I have several recommendations to address these challenges and
ensure we are taking care of our servicemembers:
1. Conduct breathing tests before and after deployment.
2. Revamp the DOD method of documenting locations where military
personnel served.
3. Utilize newer technology such as wearable particle monitors.
First, by conducting breathing tests before and after deployment
for our troops, we can determine if there is a reduction in lung
function much earlier than if we wait until disease is severe. In
addition, these data will enable better screening protocols to identify
ahead of time those soldiers at increased risk.
Second, by revamping the DOD method of documenting locations where
military personnel served, we will have a better understanding of what
these soldiers were exposed to, and therefore, a better understanding
of the cause of the illness as well as how to treat it. For example, it
is important for those treating these soldiers to know which regions of
the country an individual soldier was in; what types of munitions they
were exposed to; what the chemical makeup of these munitions are; how
trash was disposed of in that region, including burn pits; what the
weather patterns were, i.e., dust storms in that region; whether
depleted uranium was used in that region, for example, in armor
piercing rounds PGU-14 and tank shells, as well as ship ballast; and
whether that soldier used personal protective equipment and what types
of PPE they used.
Third, by utilizing newer technology such as wearable particle
monitors with GPS [Global Positioning System], we will be able to
assess a given soldier's exposure and location. By utilizing this for a
contingent of military personnel, the DOD will be better able to move
troops to regions of safety away from airborne hazards. If exposure
does happen, it will also provide critical information for treatment.
Our research team applied for a Congressionally Directed Medical
Research Program (CDMRP) grant, got a great score, but was told there
are insufficient DOD funds for the grant. We proposed to build on a
beeper sized belt mounted device which measures particle counts, sarin
and other toxic gas exposure, and gunshot sounds. Wearable tech is a
mature enough field such that the industry should be able to respond to
the needs of the DOD.
These recommendations will ease the burden on both soldiers and
physicians when those soldiers seek medical care. My recommendations do
not prevent exposure but they do allow us to provide data so we can
intercede early with diagnosis and initiation of treatment; by doing
so, then we may see the overall cost of medical care go down and, more
importantly, more lives being saved.
We know that screening and monitoring programs have been extremely
effective in preserving the health of those exposed to the World Trade
Center disaster which is an analogous plume with JP-8 in burn pits. It
is our sacred duty as Americans to protect the health of all the brave
women and men who sacrifice their lives for our freedom.
Senator Gillibrand. Thank you, so much, Dr. Rauch.
Dr. Rauch, what does DOD do in the field to track toxic
exposure for individual servicemembers, and are there any
innovative ways the Department is working to do so?
Dr. Rauch. Thank you for the question. I will start off and
my colleagues can provide any more detail.
It primarily starts, if we are talking about the deployed
environment, it primarily starts onsite with our preventive
medicine teams that are collecting environmental data, whether
it be airborne data, soil data, water data. All of that data
that is being collected--and it does, obviously, include data
that is generated from military operations, to include burn
pits, where there are--that data is collected by our preventive
medicine units. It is captured in a large database called
DOEHRS [Defense Occupational and Environmental Health Readiness
System--Industrial Hygiene], and specific to DOEHRS, it is
called DOEHRS-IH. IH stands for ``industrial hygiene.'' That
database will then become available to then feed into the ILER,
which is the longitudinal exposure record, and in addition, the
ILER will not only scrape environmental health assessment data
from DOEHRS, it will also scrape data from personnel location.
So you can match the individual servicemember and his or her
location to the environmental health data that is being
captured in DOEHRS, and then ILER will present that data in
what we call a joint longitudinal viewer and summarize that
data for the health care professional. So he or she will be
able to see where that servicemember was, at any point in time,
what they were exposed to, and be able to----
Senator Gillibrand. What is the time point this data
starts, data going back to what point in time?
Dr. Rauch. Well, preventive medicine units are part of the
deployed force, and so they could be doing their environmental
health basis on a weekly basis, they could be hanging air
monitor----
Senator Gillibrand. But when did you start collecting this
data?
Dr. Rauch. When I was on Active Duty in 1999, we were
collecting it in Bosnia and Kosovo, so it has been a while.
Senator Gillibrand. Great. Now you mentioned also--so you
have it back to 1999, at least, and you said there are active
burn pits today that you are monitoring. Where are those burn
pits located?
Dr. Rauch. It is my understanding that there are active
burn pits in the CENTCOM area of operations. I can get with
CENTCOM and we can provide more detailed information.
Senator Gillibrand. Yes, please. Because I understood that
the DOD now, as a matter of policy, has determined that they
will no longer use burn pits as a way to dispose of waste. So
if that is not the case I just need to know that, and second, I
would like to know all existing burn pits that members of the
military are being exposed to today, because that would be of
great concern.
Dr. Rauch. I will get with CENTCOM. I will provide that
information. By policy, by DOD directive, we only will use burn
pits when it is a military operational necessity. Everything
else, the COCOM, the way he or she manages that waste, will not
be managed by open burn pits.
[The information referred to follows:].
Mr. Rauch. Syria, Yemen, Iraq, Egypt, and Chad.
Senator Gillibrand. So have they determined that all past
burn pits of the last 20 years were operationally necessary?
Dr. Rauch. Can you repeat that question?
Senator Gillibrand. Have they already determined that the
hundreds of burn pits that were used in the past were all
operationally necessary?
Dr. Rauch. Burn pits that were used in the past were used
because when you establish a base camp in an immature theater,
and each servicemember in the deployed force is generating 10
pounds or more of waste every day, and you have 300 to 3,000,
that is a lot of daily waste, and we have to manage it somehow.
In an immature theater, before you can install incinerators or
contract to have it removed, burn pits were used.
Senator Gillibrand. Understood, and then my final question,
which I think you answered, but what is the process that is
currently being used by DOD and each of your services to
determine whether a servicemember returning from deployment has
been exposed to toxic fumes from burn pits during his
deployment, and how and where is that information recorded, and
who is given access to that information? Is it shared with the
VA? I think you answered that question in the beginning. Could
you just restate the answer?
Dr. Rauch. Yeah. So there a number of ways that it is
captured. We have a pre-deployment assessment and a post-
deployment assessment, and that includes questions on airborne
hazards, location exposure. In addition, we have the separation
assessment, which also includes similar questions on health
hazards and airborne contamination and location, and the
separation assessment is sent to the VA with the servicemember.
In addition, all of that is captured in databases that is
captured under ILER.
Senator Gillibrand. You believe that this data has been
captured to at least since 1999?
Dr. Rauch. The airborne monitoring that I am talking about,
that we did at Camp Bondsteel and other areas of Kosovo were
stationary air monitors. We did not have the current systems
and databases that we have today. I mean, we were writing it
down on paper and pencil, the data, back then. Now it is all
captured electronically.
Senator Gillibrand. So can you provide for the committee
what years you have environmental data for air quality in
different deployments around the globe?
Dr. Rauch. Sure. Of course.
Senator Gillibrand. Thank you.
Dr. Rauch. It would go back before 1999.
Senator Gillibrand. It would?
Dr. Rauch. Oh yes.
Senator Gillibrand. Okay. So that is excellent.
Dr. Rauch. I mean, we were doing it in the first Gulf War.
Senator Gillibrand. So we can get that information. So if
we wanted to know air quality at K2 we could get air quality
from K2?
Dr. Rauch. If I can get air quality at K2, I should be able
to, yes.
[The information referred to follows:].
Mr. Rauch. In DOEHRS, deployment air quality data exists
from 1996-present for certain locations/operations. Outside of
DOEHRS we should have at least hard copy data from Kuwait in
the early 90's (Oil Well Fires).
Senator Gillibrand. Okay. So that is kind of information we
need, because we know where there were open burn pits from
testimony of our servicemembers, and if we can get air quality
from those locations it will make their ability for the DOD to
fully understand that exposure did take place, because we have
that data. Thank you.
Dr. Rauch. I understand.
Senator Gillibrand. Thank you.
Senator Tillis. Thank you, Chairman. Thank you all for
being here. I wanted to go back. You were saying, in 1999, I am
sure that sensors have changed dramatically since then. So give
me an idea now about the training for preventative medicine
personnel about the nature of the sensors, whether or not we
are considering--I know these are area sensors, probably--but
what is the state of the art or the state of thinking in the
DOD for wearable sensors, those sorts of things, so that we can
track it down to the potential exposures of an individual in a
situation?
Dr. Rauch. Thank you, Senator. I will start that answer off
and then I am going to defer to my colleagues to add a little
bit more detail from their perspective.
We are very interested in wearables. The reason is because
our emphasis, our focus really needs to be on individual
exposure monitoring. The things that I was talking about
before, the data that we are capturing out of the environment--
--
Senator Tillis. More macro level?
Dr. Rauch. There you go, and so, you know, you are going to
have 100 or 30 or more individuals, and that data is very
difficult to pinpoint exactly what an individual was exposed
to. You know, there is kind of an old saying in science, ``It
all matters to dose response,'' and if we cannot figure out
what the dose of the exposure was, and what they were exposed
to, then it is very difficult to capture their response.
I will defer to my colleagues on their preventative
medicine units and how they train, and the technology that they
use. Captain?
Captain Feldman. Thank you, Senator. A couple of different
things from Navy Medicine. We are very proud of our forward-
deployed preventive medicine units. They are agile,
expeditionary teams that have quite a robust capability. So for
example, they have got portable sampling devices that are now
part of a tri-service, standardized program. They support all
services. In fact, they have been deployed with the Army
mostly, including currently. But those devices can conduct a
pretty comprehensive evaluation of soil, air, water, water
vapor, at an individual, portable level device having a static
sensor. So that is a robust capability that is really cutting
edge.
With regard to wearables, one unique thing that Navy
Medicine is doing with research and development, we have got
some very robust submarine atmospheric monitoring, quite a
robust and safe program, and Research and Development (R&D) is
looking at silicone bands, wearables, that you can get
individual level exposure data on a submarine.
In addition to that, our research labs in Dayton have an
Environmental Health Directorate that are looking at biomarkers
and other correlates, translating from animal models, that will
help us in the future get down to individual-level exposure.
Senator Tillis. Colonel, do you have anything to add?
Colonel Newell. Thank you, Senator. For the Department of
the Air Force it is very similar. We are looking into
wearables. We have not instituted them yet but there are in
development.
Senator Tillis. Dr. Mirza?
Dr. Mirza. Sir, thank you for the opportunity. Myself, like
my colleagues, we are also very interested in wearable
technology. I think it is also important to underscore that the
Army preventative medicine detachments are quite skilled and
equipped to conduct the ambient samplings that they do as part
of missions when they are forward deployed. Certainly air
quality is not the exclusive issue of concern as well as other
environmental issues, such as vector-borne diseases, pest
control management, communicable diseases, and they are
equipped and trained in that respect with environmental
engineers, scientists, and also complementary clinical staff
and public health and preventive medicine that are able to
provide adjunctive and consultive support on-site, and not only
within the PM community but also for all providers that are
downrange.
It is a pretty synchronized and robust capability that the
Army provides in a contingency operation to assess exposures
and respond to them.
Senator Tillis. You know, I think one of the reasons why we
should focus so much on wearables is we get an atomic view of
exposures, and then hopefully, as a part of the process that is
being captured in the electronic health record of the
individual servicemember and ultimately being transferred to
the electronic health record for the veteran, now that we have
a joint office for the Center implementation for the VA
electronic health record.
I think it is going to be very important to have a seamless
transition, and then hopefully we get to a point, if you are
able to capture enough data, to where we can apply predictive
analytics to maybe identify an exposure long before any
symptoms have manifested themselves.
Dr. Rauch, did you have something to add?
Dr. Rauch. Well, I would also add, Senator, that in
addition to wearables we need to understand more about how the
individual responds to environmental exposures. What risks do
they bring, other backgrounds, lifestyle factors such as, are
you smoking a pack a day, you know, before you deployed, other
lifestyle factors, or even what genetic background individuals
bring. We need to understand those because they are going to
have an impact, and the science is not there yet but we are
pursuing it.
Senator Tillis. [Presiding.] Thank you. Senator Hawley.
Senator Hawley. Thank you, Senator Tillis. Dr. Rauch, if I
could just start with you. You testified in your written
testimony that since 2001, over 4 million now veterans as well
as DOD civilians and DOD contractors deployed to the Southwest
Asia theater of operations. How many of these individuals would
have been exposed to airborne hazards, including toxic
exposures from burn pits? Do you know? In that time frame.
Dr. Rauch. Well, I cannot imagine that--all of them should
have been exposed to some types of airborne hazards if they
were deployed in various base camps and environments in
Southwest Asia, because Southwest Asia, just the military
operational environment--vehicles, burn pits, everything else,
to include sandstorms created a lot of potential for airborne
hazards. If you are there, you are exposed to it.
Senator Hawley. What is DOD's estimate for the number of
individuals who would qualify for the presumption of service-
related connection, given how many individuals were exposed,
and so on?
Dr. Rauch. I have got to take that for the record. I will
get you as much detail as I can, but I cannot get that to you
off the top of my head, Senator.
[The information referred to follows:].
Mr. Rauch. Thus far, VA has established three presumptions
for asthma, rhinitis, and sinusitis related to fine particulate
matter, along with nine rare respiratory cancers. At present it
is unknown how many individuals (veterans) would qualify for
one of these presumptions. Additional analysis in coordination
with the VA is required to provide an answer to the question.
Senator Hawley. That is fine. We will take it for the
record and I will look forward to your answer.
What was the practice of burn pits in other theaters during
this period of time, from 2001 forward? Do you know, Dr. Rauch,
aside, that is, Southwest Asia?
Dr. Rauch. What other burn pits in other combatant
commands?
Senator Hawley. Mm-hmm.
Dr. Rauch. I will take it for the record. Most of them
should have been in the CENTCOM AOR [area of responsibility],
though.
[The information referred to follows:].
Mr. Rauch. Since 2001, burn pits were predominately used in
Southwest Asia, Afghanistan, and Africa (specifically Egypt,
Chad, and Djibouti). DOEHRS includes an environmental report
indicating a burn pit operated by Philippine forces in the
vicinity of where United States Force were stationed during
Operation Enduring Freedom.
Senator Hawley. Okay. So if they are in the CENTCOM AOR
then they are in this same region that we have been talking
about, roughly.
Tell me about DOD's collection of this data. I mean, we are
dealing with servicemembers' exposure to toxins, burn pit
toxins, other airbornes. It seems like we have very limited
data for a lot of this. Why is that? Why is it the DOD has not
collected this kind of data for so long? Can you give me any
insight?
Dr. Rauch. Well, I think we have always improved on the
extent of the data and the technologies that we collect the
data with, and we continue to improve. I mean, we collect a lot
of environmental health assessment data, you know, the number
of compounds and the number of airborne compounds, particulate
matter, compounds that are in the motor pool over there, the
compounds in the soil that get aerosolized as a result of
operations. A lot of that is collected, and it goes into a
database that we call DOEHRS, and DOEHRS is a large database
that can then feed into ILER, which is what I was talking
about, which is Individual Longitudinal Exposure Record, that
pinpoints the location of the servicemember with all of that
environmental data. Therefore, the health care provider can
take a look and get kind of a summary of where the
servicemember was, what the environmental hazards were in that
area, and can best form a treatment regime for that
servicemember.
Senator Hawley. What about data available for assessing the
linkages between exposure that we have been talking about, to
airborne toxins, including particularly from burn pits, and
certain kinds of illnesses? What has DOD been doing to improve
data collection on that score, and data analysis?
Dr. Rauch. Well, so it is a part of the data that we
already collect, by preventive medicine units, and store in our
databases. But linking those exposures to illnesses has been
somewhat challenging. A couple of years ago, the National
Academy of Sciences said that there is consistent data from
exposures in Southwest Asia to our deployed force and illnesses
such as persistent cough, asthma, and a few other respiratory
disorders.
More data is needed, and more specific data linking
individuals to certain airborne hazards and their health
outcomes is needed to be able to expand that list.
Senator Hawley. I will circle back to you on the questions
for the record. I will probably have a few more as well. Thank
you, Mr. Chairman.
Senator Tillis. Just a couple of follow-ups. Senator
Gillibrand went to vote. She is probably waiting on the second
vote to be called. I am kind of curious about when ILER will be
fully interoperable with DOD electronic health record and the
VA's electronic health record. What is the timeline?
Dr. Rauch. Yeah, the timeline for full capability is 2023,
but it is capable now but a little bit less limited.
Senator Tillis. With the DOD electronic health record,
because I guess the VA electronic health record is in a
multiyear implementation, so that would probably have to track
along with their ultimate build-out?
Dr. Rauch. That is my understanding.
Senator Tillis. Okay. Tell me a little bit about DOD-funded
research on taking the information that we have about
potentially toxic exposures and making certain presumptions
about how that exposure could have caused a bad outcome for a
servicemember, so-called presumptions.
Dr. Rauch. Sure. So with regard to human studies, most of
the human studies, human research that we sponsor, and continue
to sponsor, really compares a group of deployers to a control
group of non-deployers, to take a look at location,
environmental health assessments, what were the threats over
there, and then look at the differences in terms of the
incidence of health outcomes between the deployed force in that
area and the control or non-deployers.
In addition to that, we also have experiments. We have
animal experiments at the Air Force, at Wright Patt, up at the
711th, which are looking at exposure to experimental animals of
different airborne hazards, to include compounds that you would
see in burn pits and also airborne sand and dust that you would
see in that deployed environment, and looking at the health
effects, health outcomes in experimental animals.
Those are just a few. If my colleagues want to add
anything, please do.
Senator Tillis. Captain?
Captain Feldman. Thank you, Senator. I am aware of a lot of
work by the Navy Medical Research Command and the Naval Health
Research Center, which is based in San Diego. They have got, in
addition to collaborating with the VA on these studies they
have got a Millennium Cohort, which is a powerful source of an
extremely large population that is allowing them to explore all
of these questions. I will defer to my colleagues before
getting into specifics. Thank you.
Colonel Newell. We already--thank you, Senator--we already
know that there are a lot of medical symptoms and diseases that
are associated with open burn pits and other airborne toxins,
but it is difficult to find a direct link to those at this
time. But there are many studies that are underway that are
looking into that, and hopefully in the future we will be able
to link that.
I think the important thing with the ILER is the ILER
captures the data, it links it to the individual, and it also
capture data from when the individual returns from deployment,
and asks them specifically if they have any symptoms or have
any concerns with airborne hazards or chemicals. If they answer
that to the affirmative there is always a provider that is
going to talk to them one-on-one and address that with them.
They also have a post-deployment health assessment that
occurs 90 to 180 days after they get back, and it is the same
questions. They ask them, do you have any symptoms or any
concerns you have with airborne hazards and chemicals, and once
again, if those are answered in the affirmative then the
provider gets with them and they talk to them.
Again, during the preventative health assessment that
specifically goes into those questions again, and this is
something that every member of the Department of Air Force gets
annually. They ask the same questions and they also go into the
Open Burn Pit Registry. They courage all members to register
for that if they have been in a deployed area with an open burn
pit. Even if they do not have any symptoms or any concerns they
are encouraged to go ahead and register for that, and once
again, a provider will reach back and talk with them and go
over any questions or concerns that they might have.
Senator Tillis. Dr. Mirza?
Dr. Mirza. Thank you, Senator. In our organization, at the
Army Public Health Center, we have engaged in several
epidemiological studies, and in those studies we essentially
use deployment history as a proxy for exposures. Of course,
that can include exposures to burn pits but also to the poor
air quality conditions within the area of operations. We also
take that information and we look at the health status of those
individuals before they deployed and after they deployed, to
make determinations about whether or not associations existed
for particular respiratory disorders of interest.
What we have found is that these epidemiological studies
are not always very conclusive, and a lot of that has to do
with limitations of the study, because we do not necessarily
have individualized exposure information tied to individuals
and their health outcomes. That is significant limitation.
But what we do have the strongest evidence to suggest is
that respiratory symptoms are present in many deployers into
the CENTCOM area of operations, as a function of the air
quality issues that are there. So their symptoms are like
shortness of breath, cough, phlegm production, decrements in
their ability to successfully pass their physical performance
tests, and things of that nature. So we have that information.
Other studies have been conducted looking at deployers
themselves, and looking at them prospectively, how they have
been managed clinically and what conditions they have suffered
as a consequence of their deployment, particularly looking at
respiratory conditions. A small study that was conducted looked
at those particular deployers and determined about half of
those individuals did not have necessarily diagnosable
respiratory conditions per se, despite the fact that they had
symptoms that they complained about, but the other half seemed
to have symptoms consistent with asthma and hyperreactivity of
the airway and such.
So the bottom line is there has been a lot of studying
occurring about deployers and their respiratory health and the
potential associations that exist with their deployment, but
based on limitations on exposure data it is very difficult to
make strong conclusions about the source of exposure and those
health outcomes.
Senator Tillis. Thank you.
Senator Gillibrand. [Presiding.] The Department's prepared
statement for this hearing states that peer-reviewed published
research documents that military personnel deployed to Iraq and
Afghanistan appeared to experience elevated rates of acute
upper respiratory symptoms during deployment and may be at
greater risk for post-deployment respiratory symptoms and
respiratory illnesses. Dr. Mirza, Dr. Newell, and Dr. Feldman,
please describe what your service does to ensure that
servicemembers concerned about potential health effects of
exposure to airborne hazards receive appropriate health care,
and is this care documented in their health records, and will
this information be available to the VA when the servicemember
leaves service and receives care through the VA?
Colonel Newell. Senator, thank you for that question. I
will walk you through essentially a process that we undertake.
First, when individuals are in a deployed environment and they
are suffering with any respiratory illness--let me take a step
back--any illness or any symptoms, we have medical personnel,
we have medical centers that are deployed, or MTFs that are
deployed there with the personnel to respond to those concerns.
Those get documented and are available throughout the course of
that servicemember's service treatment record, to be looked at
prospectively.
When these individuals redeploy, they come back home, they
undergo post-deployment health assessment, and there are
essentially two parts to that. One is a screening
questionnaire, in which these individuals self-report concerns
about their health, their respiratory symptoms, and other
organ-associated symptomatology of interest, and we also ask
about their concerns about environmental exposures, a whole
scope of exposures, not necessarily airborne but chemical and
so on.
Once they complete that self-assessment these individuals
then are evaluated by a provider and they are given that option
for a focused medical evaluation, based on any concerns that
they have advocated for on that self-assessment.
Routinely, we conduct periodic health assessments. This has
a couple of purposes. The first is to assure that individuals
are assessed annually, that they maintain the medical standards
and a certain level of physical fitness to be able to do their
job. The second is to also identify any health outcomes or
health issues of personal concern that need to be evaluated and
managed further, either by a primary care provider or a
specialist that is going to be referred in for their care. But
also as a function of that periodic health assessment, it is an
additional opportunity to ascertain any personal concerns that
individual may have about exposures within the environment in
which they operate, soldier, or deployed to.
You know, essentially there are three main points of care,
in my view, in which these individuals are evaluated, is
downrange if they are experiencing symptoms, it is when they
return home, as a function of the post-deployment health
assessment process, and it is also at least annually, on a
periodic basis, when they are going through a period health
assessment.
Captain Feldman. [Off microphone]--but that information
comes back as the deployers come home, with both their pre- and
post-deployment surveys and periodic health assessments and
there are specific questions that are verbally reviewed on this
questionnaire to ensure that dialogue happens with the
clinician. If you know you were exposed to a location it is in
the registry. If those clinicians do not have the expertise in
their primary care [inaudible] environmental health
specialists, industrial health hygiene specialists who consult
with those clinicians are available. In addition to that
[inaudible] are another layer of consultative expertise for
those specific questions that, when a patient comes to a clinic
visit and has that concern, those are resources that
[inaudible] that individual patient.
Senator Gillibrand. Thank you, and Colonel Newell.
Colonel Newell. Thank you, Senator. I agree with my
colleagues. I will just add on that the ILER does report those
specific questions that we ask about airborne hazards, and so
it pulls that. So not only are you looking at the occupational
environmental health risk assessments of when the member was
downrange, multiple times, and you are reviewing those
exposures, it is taking those little bits of questions that the
member has answered regarding airborne hazards from the post-
deployment health assessment and the periodic health
assessment.
We also have a new separation health assessment that has
been under development for the last year. It should be released
this fall. It also goes into detail about airborne hazards and
chemicals of that nature, and that will also be documented.
Senator Gillibrand. Thank you. Any further questions?
Senator Tillis. Just one. I just want to echo Senator
Gillibrand, or re-emphasize Senator Gillibrand on current
active burn pits. Some of the process that led to these being
operationally necessary I think would be very helpful for the
committee.
Thank you for being here.
Senator Gillibrand. Thank you very much for your testimony.
I welcome the second panel to come up. Thank you very much.
[Pause.]
Senator Gillibrand. I now welcome the second panel, Dr.
Anthony M. Szema, Director, International Center of Excellence
in Deployment Health and Medical Geosciences, Northwell Health
Foundation; Mr. Tom Porter, Executive Vice President for
Government Affairs, Iraq and Afghanistan Veterans of America;
Mrs. Rosie Torres, Executive Director, Burn Pits 360; and Mr.
Steven Patterson, Former Environmental Science Officer,
Combined Joint Task Force, 101 Headquarters, Afghanistan, from
2008 to 2009.
Thank you so much, and each of you can give you opening
statements. Dr. Szema, you can go first.
STATEMENT OF ANTHONY SZEMA, MEDICARE, DIRECTOR, INTERNATIONAL
CENTER OF EXCELLENCE IN DEPLOYMENT HEALTH AND GEOSCIENCES,
NORTHWELL HEALTH FOUNDATION
Dr. Szema. Thank you, Chair Gillibrand, Ranking Member
Tillis, members of the Personnel Subcommittee of the Senate
Armed Services Committee for the opportunity to participate in
today's hearing.
Between 1998 and 2015, I was Allergy Section Chief,
Veterans Affairs Medical Center, Northport, New York, and my
expertise on this issue stems from the following. My team first
reported new-onset asthma among soldiers to Iraq and
Afghanistan with exposure to burn pits in 2007. We described
deployment-related rhinitis in 2008; coined the term Iraq
Afghanistan War Lung Injury, IAW-LI, in 2011, based on lung
function testing data; developed animal models with burn pit-
based dust in 2014; tested candidate drugs in these mice in
2018; and co-invented new candidate medicines this year.
I am testifying because as a physician I care about the
health and well-being of my patients who are our soldiers. The
team in my office sees numerous patients post-deployment with a
variety of symptoms, which include shortness of breath, cough,
and chest pain which is accentuated with exercise. I have
diagnosed post-burn pit-exposed soldiers with asthma, non-
smoking-related accelerated COPD, constrictive bronchiolitis,
carbonaceous burned lung, titanium lung, lung fibrosis, bladder
cancer, and pulmonary ossification, or bone in the lung. In one
severe case, for example, one of my patients with lung fibrosis
underwent two lung transplants. He just died in December.
As an expert in the field I have concluded that these lung
disorders are directly related to exposure to airborne hazards,
including burn pits, dust storms, improvised explosive devices,
and blast-over pressure from mortar-fired rounds.
As doctors treating these patients, one challenge we face
is that there is inadequate screening of these military
personnel, who are predisposed to lung injury. Lack of
screening means they never get diagnosed, they get diagnosed
late, or they get diagnosed when it is irreversible.
The dilemma with military personnel who typically do not
have asthma, who pass basic training outdoors, whose masks must
be fit for deployment at Fort Hood, is that they do not have
pre-deployment pulmonary assessments, unlike the Fire
Department of New York, which was able to determine lung
function reduction after 9/11. An otherwise healthy soldier who
has 100 predicted pre-deployment who goes down to 80 percent
has a significant decrease.
Another challenge we face is that doctors treating these
servicemembers is a lack of information we receive. Without
knowing what they are exposed to or potentially exposed to it
is hard to prove what caused the ailment. For example, last
month one patient of mine was denied a consult to the East
Orange War-Related Illness and Injury Center because the local
VA doctor said he did not believe that that military
firefighter's sleep apnea, sinusitis, asthma, and rhinitis were
related to deployment, even though he had a positive sleep
study during Active service.
Even if it is known that there are toxic materials at
certain sites, often soldiers visit our academic center without
complete documentation of locations of their deployment, so
their direct exposure cannot be proven. This is especially the
case if they were at forward operating bases like Camp Stryker,
whose exact location is not on the map.
I have several recommendations to address these challenges
and ensure we are taking care of our servicemembers. One,
conduct breathing tests before and after deployment. Two,
revamp the DOD method of documenting locations where military
personnel serve. Three, utilize newer technology such as
wearable particle monitors.
First, by conducting tests before and after deployment we
can determine if there is a reduction in lung function much
earlier than if we wait. In addition, these data will better
enable screening protocols to identify who are soldiers at
risk.
Second, by revamping the DOD method of documenting
locations where military personnel service we will have a
better understanding of what they are exposed to, a better
understanding of the illness and how to treat it.
Third, by utilizing newer technology such as wearable
particle monitors with GPS, we will be able to assess a given
soldier's exposure and location. By utilizing this for a
contingent of military personnel, the DOD will be better able
to move troops to regions of safety, away from airborne
hazards. If exposure does happen, it would also provide
critical information for treatment.
We know that screening and monitoring programs have been
extremely effective for those victims of the World Trade Center
disaster post-9/11, and this is an analogous exposure with JP-8
and burn pits. It is our sacred duty to care for the women and
men who sacrifice their lives for our freedom.
[The prepared statement of Dr. Anthony Szema follows:]
Prepared Statement by Dr. Anthony Szema
I thank Chair Gillibrand, Ranking Member Tillis and the members of
the Personnel Subcommittee of the Senate Armed Services Committee for
the opportunity to participate in today's hearing.
My name is Dr. Anthony Szema, Clinical Associate Professor of
Medicine (Divisions of Pulmonary/Critical Care and Allergy/Immunology),
and Clinical Associate Professor of Occupational Medicine, Epidemiology
and Prevention at the Donald and Barbara Zucker School of Medicine at
Hofstra/Northwell where I am Director, International Center of
Excellence in Deployment Health and Medical Geosciences. At Stony Brook
University, as adjunct faculty, I am Research Assistant Professor,
Department of Technology and Society, College of Engineering and
Applied Sciences.
Between 1998 and 2015 I was Allergy Section Chief, Veterans Affairs
Medical Center, Northport, NY. My expertise on this issue stems from
the following: my team first reported new onset asthma from Iraq and
Afghanistan Deployments among burn pit exposed soldiers in 2007,
described deployment related rhinitis in 2008, coined the term Iraq
Afghanistan War Lung Injury (IAW-LI) in 2011, based on lung function
testing data, developed animal models with burn pit base dust in 2014,
tested candidate drugs in mice in 2018, and co-invented new candidate
medicines this year.
I agreed to testify because, as a physician, I care about the
health and well being of my patients who are our soldiers.
The team in my office sees numerous patients post deployment with a
variety of symptoms which include shortness of breath, cough, and chest
tightness that is accentuated with exercise. I have diagnosed post burn
pit exposed soldiers with asthma, chronic obstructive pulmonary
disease, lung fibrosis, carbonaceous lung, constrictive bronchiolitis,
titanium lung, bladder cancer as well as pulmonary ossification or bone
in the lung. These are previously healthy, non-smoking, fit for
deployment soldiers who have newly acquired lung disorders after their
tours of duty. In one severe case, for example, my patient with lung
fibrosis required two lung transplants and died last December.
As an expert in the field, I have concluded that these lung
disorders are directly related to exposure to airborne hazards. These
ailments resulted from inhalational exposures to: burn pits, dust
storms, improvised explosive devices, as well as blast overpressure
from mortar fired rounds.
My conclusions are based on our analyses of lung biopsies
containing particles from these soldiers' lungs. These particles were
subsequently processed at two different sites with two different types
of technical machinery for analysis.
1) Center for Extraplanetary Exploration, Rahman Spectroscopy,
Department of Geosciences, Stony Brook University
2) Brookhaven National Laboratory, National Synchrotron Light
Source II Beam ID-5.
Analyses from both laboratories conclude that the particles from
soldiers' lung biopsies sustained exposure to high combustion
temperatures consistent with burning. Chemicals identified included
polycyclic aromatic hydrocarbons (PAH), and metals such as titanium and
iron. These metals were bound together. These metals were also
oxidized--which is evidence they were burned.
As doctors treating these patients, one challenge we face is that
there is inadequate screening for those military personnel who are
predisposed to lung injury. Lack of screening is a challenge for
diagnosing and treating patients for several reasons. First, if
individuals are not screened, then they may never get correctly
diagnosed. In addition, if they are not screened, and therefore not
treated properly, by the time they present to the doctor, the disease
is already severe and therefore, more difficult to treat.
The dilemma with military personnel, who typically do not have
asthma, since it is an exclusion diagnosis for enlistment, who must
pass basic training outdoors, and who must be fit for deployment at
Fort Hood prior to deployment, is that they usually do not have pre-
deployment pulmonary assessments.
Unlike the Fire Department of New York which requires annual
spirometry breathing tests and was able to assess respiratory changes
after 9/11, soldiers most often do not have a baseline for comparison
other than their 2-mile run time. An otherwise healthy young soldier
may be 100 percent or more predicted on spirometry and oxygen
consumption from a cardiopulmonary exercise test predeployment. So,
reduction to 80 percent predicted post-deployment is a significant
decrease even though 80 percent is the cutoff for normal.
Another challenge we face as the doctors treating these
servicemembers is the lack of information we receive. Without knowing
what they were exposed, or potentially exposed, to, it is hard to prove
what caused the ailment. For example, in one recent case last month, a
military firefighter, a patient of mine, was unable to get a referral
to the East Orange WRIIC. The primary care doctor in the local VA did
not believe that the military firefighter's sleep apnea, sinusitis,
asthma, and rhinitis were related to deployment, even though he had a
positive sleep study during his Active Duty.
Even if it is known that there were toxic materials at a certain
site, too often, soldiers visit our academic center without complete
documentation of locations of their deployment so their direct exposure
cannot be proven. This is especially the case if they were at forward
operating bases or places like Camp Stryker whose exact location is not
on the map.
I have several recommendations to address these challenges and
ensure we are taking care of our servicemembers:
1. Conduct breathing tests before and after deployment.
2. Revamp the DOD method of documenting locations where military
personnel served.
3. Utilize newer technology such as wearable particle monitors.
First, by conducting breathing tests before and after deployment
for our troops, we can determine if there is a reduction in lung
function much earlier than if we wait until disease is severe. In
addition, these data will enable better screening protocols to identify
ahead of time those soldiers at increased risk.
Second, by revamping the DOD method of documenting locations where
military personnel served, we will have a better understanding of what
these soldiers were exposed to, and therefore, a better understanding
of the cause of the illness as well as how to treat it. For example, it
is important for those treating these soldiers to know which regions of
the country an individual soldier was in; what types of munitions they
were exposed to; what the chemical makeup of these munitions are; how
trash was disposed of in that region, including burn pits; what the
weather patterns were, i.e., dust storms in that region; whether
depleted uranium was used in that region, for example, in armor
piercing rounds PGU-14 and tank shells, as well as ship ballast; and
whether that soldier used personal protective equipment and what types
of PPE they used.
Third, by utilizing newer technology such as wearable particle
monitors with GPS, we will be able to assess a given soldier's exposure
and location. By utilizing this for a contingent of military personnel,
the DOD will be better able to move troops to regions of safety away
from airborne hazards. If exposure does happen, it will also provide
critical information for treatment.
Our research team applied for a Congressionally Directed Medical
Research Program (CDMRP) grant, got a great score, but was told there
are insufficient DOD funds for the grant. We proposed to build on a
beeper sized belt mounted device which measures particle counts, sarin
and other toxic gas exposure, and gunshot sounds. Wearable tech is a
mature enough field such that the industry should be able to respond to
the needs of the DOD.
These recommendations will ease the burden on both soldiers and
physicians when those soldiers seek medical care. My recommendations do
not prevent exposure but they do allow us to provide data so we can
intercede early with diagnosis and initiation of treatment; by doing
so, then we may see the overall cost of medical care go down and, more
importantly, more lives being saved.
We know that screening and monitoring programs have been extremely
effective in preserving the health of those exposed to the World Trade
Center disaster which is an analogous plume with JP-8 in burn pits. It
is our sacred duty as Americans to protect the health of all the brave
women and men who sacrifice their lives for our freedom.
Senator Gillibrand. Thank you, Dr. Szema. Mr. Porter?
STATEMENT OF TOM PORTER, EXECUTIVE VICE PRESIDENT, GOVERNMENT
AFFAIRS, IRAQ AND AFGHANISTAN VETERANS OF AMERICA
Mr. Porter. Thank you for having us here, Senator
Gillibrand and Senator Tillis. I appreciate everything you are
doing on this issue.
I would like to introduce my daughter, 13-year-old daughter
here, Elizabeth Porter. She is playing hooky from school today,
so hopefully she gets something out of this.
On a more serious note, I want to take this opportunity to
say that my thoughts and prayers are with Dr. Kate Hendricks
Thomas, advocate on this issue. She is going through a very
particularly tough time with regard to her burn pit-related
illness.
So I am here not only as an IAVA advocate but as one who
was exposed to a variety of airborne toxins from burn pits and
other sources while I was deployed. Before I went downrange I
had completely healthy lungs. Shortly after I arrived in Kabul,
in 2010, where the air was particularly bad, my lungs had a
severe reaction and became infected. It was controlled with
medication, but I was diagnosed with asthma as soon as I got
back home a year later. But I have to still take the
medications to keep breathing.
Exposure to burn pits used by military to destroy medical
and human waste, chemicals, petroleum, other trash, it has been
widespread. We have talked about this a lot here already. It is
not just burn pits. You could learn a lot from those who have
served in Kabul, for example. It is an enormous city without a
modern sewage system. Many who served there are suffering the
impacts from breathing airborne feces for extended periods of
time, and there are also burn pits there, at many of the bases
in that city alone.
At every location where U.S. and coalition military were
stationed there were many port-o-johns. It was somebody's job
to pull out that metal bin from the port-o-john every day,
douse it with jet fuel, and burn it down to a brick, and that
is how you get rid of the port-o-john waste. It is somebody's
job to do that, and I do not need to describe it, but it is a
particularly nasty job.
The military and veteran community know all too well how
detrimental these toxic exposures can be. I will refer to our
new Member Survey that is just out this month, for 2022. We
survey our members. Eighty-two percent of our members say they
experienced toxic exposures during their service. Of those, 90
percent say they have or may have symptoms as a result. Of the
82 percent who were exposed, just 53 percent said they had
their exposures documented in their DOD Periodic Health
Assessments, so just 53 percent.
This data shows the enormous percentage of those who are
suffering service-related exposures, especially considering the
estimate the VA has of as many as 3.5 million that could have
been exposed.
When IAVA saw similar data in a previous Member Survey we
conceived of and worked hard to pass the Burn Pits
Accountability Act that was passed in 2020, within the NDAA.
The law required servicemembers to be evaluated for exposures
during routine health exams. Servicemembers were required to be
enrolled in the Burn Pit Registry, unless they opt out, if they
suffered exposures or if they were stationed near a burn pit.
Seventy-six percent of IAVA members were aware of the
registry but only 59 percent are registered in it. DOD must
maximize its efforts to ensure all who are eligible get
enrolled, not just informed of it, as the law requires. It
requires them to be enrolled in the registry, and that is the
intent behind the law in the first place, and we know this
because we worked to develop the bill and passed it.
IAVA would like DOD to confirm if the letter and intent of
the Burn Pits Accountability Act is being executed, including
whether servicemembers are actually being required to enroll in
the registry, or simply being advised of its existence.
We heard a lot of talk already today about the ILER
database. That is really critical, we believe. That would help
inform servicemembers, veterans, and the medical providers of
the exposures by your location and the time you were deployed.
I think we heard that it was supposed to be operational in
2023, September of 2023 is what I understand. We supported
legislation that required that veterans have access to their
ILER database online. So hopefully that stays on track for
implementation by September 2023, and we would like your
assistance to try to ensure that that happens.
There has also been some talk in the news about the Red
Hill fuel storage facility in Hawaii. This is another toxic
exposure, so it is not all burn pits. We want to make sure that
the DOD documents those exposures to not only the
servicemembers that are serving there now but have been
dislocated, but then also those that have been impacted over
the life of the fuel storage facility. That is important. How
are they going to be doing that?
Serving in the military is tough on one's body. I do not
think that is surprising to anybody here. Although not specific
to toxic exposures, a significant indicator of IAVA members'
health, when asked in our Member Survey how they would rate
their overall health before joining the military, 91 percent
rated their health as excellent or good. When asked how they
rated their heath after they left the military, just 33 percent
said it was excellent or good.
The military service can be hard and cause adverse health
impacts. It is not a surprise. But those who may want to
encourage their sons and daughters to enter the military except
that if one does suffer injuries our government will care for
them when they come home. Failure to care for the many who
suffered toxic exposures many diminish the value of military
service in the public's eyes, and by refusing to satisfy our
obligations to them we communicate to current and future
servicemembers that we do not actually have their backs.
So on behalf of the 3.5 million servicemembers and veterans
who may have suffered toxic exposures I implore you to ensure
that DOD follows recently enacted laws meant to increase
transparency and information-sharing with those who have
suffered exposures and to spare no effort in not only
anticipating new hazards our personnel may encounter but advise
them of their known risks ahead of time so they and medical
professionals are better equipped to address emergent health
impacts.
Again, thank you very much for having me today, and I am
happy to answer any questions.
[The prepared statement of Mr. Tom Porter follows:]
Prepared Statement by Mr. Tom Porter
Chair Gillibrand, Ranking Member Tillis, and Members of the
Subcommittee, thank you for having me here today to talk about the most
widespread health impact suffered by the post-9/11 generation.
On behalf of Iraq and Afghanistan Veterans of America (IAVA) and
our more than 425,000 members, thank you for the opportunity to share
our views, data, and experiences on the matter of burn pits and other
toxic exposures, what many are saying is the ``Agent Orange'' of our
generation.
I am here not only as an IAVA advocate for post-9/11 veterans, but
as one who was exposed to a variety of airborne toxins from burn pits
and other sources at many locations when I was deployed to during the
Global War on Terror in Afghanistan and the Middle East between 2007
and 2014.
Before I went downrange during that period, I had zero breathing
problems and completely healthy lungs. In the first couple of weeks
after I arrived in Kabul, where the air is particularly bad, my lungs
had a severe reaction and became infected. It was controlled with
medication over the next year. However, after re-deploying home, I
stopped the medications and symptoms came back and I was diagnosed with
asthma as a result of my deployment.
Exposure to burn pits used by the military to destroy medical and
human waste, chemicals, paint, metal/aluminum cans, unexploded
ordnance, petroleum and lubricant products, plastics, rubber, wood, and
other waste has been widespread.
It is not just burn pits. Search for the ``Poo Pond Song'' on
YouTube and you will hear one soldier's humorous take on the enormous
lake of human waste that tens of thousands of international
servicemembers lived, worked, and ate around at our formerly large base
in Kandahar.
You could also learn from the many who have served in Kabul--an
enormous city without a modern sewer system. Many of our veterans who
served there are suffering the impacts from breathing airborne feces
for extended periods of time. There have been burn pits at the numerous
previous bases there as well.
At every location where U.S. and coalition military were stationed,
there were many many port-o-johns. The waste from all those toilets had
to be disposed of on a regular basis. It was someone's job to routinely
pull out the metal bin of waste, douse it with jet fuel, and burn it
down. Of course, we cannot forget the omnipresent diesel generators to
power our operations wherever we have been deployed that emitted black
smoke around the clock. These presented another constant airborne
assault on the health of our servicemembers.
The military and veterans community knows all too well how
detrimental all these toxic exposures and environmental hazards can be,
and the associated health impacts. As an example, IAVA's 2022 Member
Survey of our mostly-post-9/11 veterans and Active Duty personnel,
being released this month, show the following:
Eighty-two percent of our members surveyed across all services,
with slightly more in the Army and Marine Corps, say they experienced
toxic exposures during their service. Of those, 90 percent say they
have or may have symptoms resulting from their exposures. Also of the
82 percent who were exposed, just 53 percent said they had their
exposures documented in their DOD Periodic Health Assessment.
This aforementioned data shows the enormous percentage of those who
are suffering service-related exposures, especially when referenced in
the context of the VA estimate of 3.5 million it says may have
experienced exposures.
When IAVA saw similar data in a previous Member Survey, we
conceived of and worked hard to pass the Burn Pits Accountability Act
(BPAA) sponsored by Sens. Amy Klobuchar and Dan Sullivan, which was
signed into law as part of the 2020 NDAA. The BPAA language in Section
704 required servicemembers to be evaluated for exposure to toxic
airborne chemicals during routine health exams and directs the DOD to
record and share whether servicemembers were based or stationed near an
open burn pit, including any information recorded as part of the
Airborne Hazards and Open Burn Pit Registry, the Periodic Health
Assessment (PHAs), Separation History and Physical Examination (SHPEs),
and Post-Deployment Health Assessment (PDHAs). Members were also
required to be enrolled in the Burn Pit Registry, unless they choose to
opt out, if they were exposed to toxic airborne chemicals or stationed
near an open burn pit.
Seventy-six percent of IAVA members are aware of the Burn Pit
Registry, but only 59 percent are registered, according to our Member
Survey. DOD must maximize its efforts to ensure all who are eligible
and are willing to enroll, get enrolled.
IAVA would like this Committee to confirm with DOD if the letter
and intent of the BPAA is being executed, including whether
servicemembers are actually being required to enroll in the Registry
(unless they opt out) or are simply being advised of the existence of
the Registry.
An important next step forward for servicemembers and veterans who
have been exposed is the joint VA-DOD development of the Individual
Longitudinal Exposure Record (ILER) database. The ILER will record
potential and known exposures throughout a servicemember's time in
uniform in order to provide DOD and VA clinicians, claims adjudicators,
and benefits advisors actionable data needed to improve the care
provided to servicemembers and veterans. Data from those receiving
treatment for illnesses through DOD and VA should be fed back into the
ILER, ultimately increasing VA's ability to develop a presumptive
illness database of evolving illnesses.
If this system is done right, it will provide servicemembers and
veterans significant transparency into their exposures that many have
been saying has been lacking by DOD and VA. However, while this system
has tremendous potential in allowing servicemembers, veterans, and
their medical providers access to critical exposure information, ILER
is not available currently to servicemembers and veterans.
IAVA supported language included in the Mac Thornberry NDAA for
Fiscal Year 2021 that required the VA Secretary to ``provide to a
veteran read-only access to the documents of the veteran contained in
the [ILER] in a printable format through a portal accessible through [a
VA website].'' The VA-DOD Joint Executive Committee has said in its
2019 Annual Report that the ILER achieved initial operating
capabilities on September 30, 2019 and that it will achieve full
operating capabilities by September 2023.
IAVA asks that this Committee confirm with DOD that the ILER is
indeed operationally capable and accessible for servicemembers and
veterans on schedule for use in 2023.
As we recently learned, Defense Secretary Austin announced on March
7 that he decided to defuel and permanently close the Red Hill bulk
fuel storage facility in Hawaii. The Secretary committed to
environmental remediation of the location, and he also addressed the
associated workforce and their families, recognizing that their health,
lives and livelihoods have been impacted and that ``We owe you the very
best health care we can provide, answers to your many questions, and
clean, safe drinking water . . . '' and a ``return to normal.'' IAVA
would like to know specifically how they are tracking the effects on
the people who have suffered exposures. Not just the ones who live
there now, or that have been evacuated, but those who have been
affected over the life of the impacts by the facility. Will these
exposures be included in the servicemembers' health records that will
be transferred to the VA when they leave service? IAVA would have
similar concerns with how DOD is tracking the health effects in
military personnel and their families who were exposed at any DOD
facility or military base.
Serving in the military is an honorable calling, but it is tough on
one's body.
Although not specific to toxic exposures, a significant indicator
of IAVA members' health, when asked in our Member Survey how they would
rate their overall health before joining the military, 91 percent rated
their health excellent (65 percent) or good (26 percent). When asked
how they rated their health after they left the military, just 33
percent said it was excellent (6 percent) or good (27 percent).
This is probably not a surprise to many, that military service can
be hard and cause adverse health impacts, and those joining the
military likely understand that too. But our servicemembers, recruits,
and parents who may want to encourage their sons and daughters to enter
service expect that if one does suffer injuries, our government will
properly care for them when they come home.
Failure to care for the many thousands who suffered military toxic
exposures may diminish the value of military service in the public's
eyes. By refusing to satisfy our obligations to them we communicate to
current and future servicemembers that we do not actually have their
backs.
So, on behalf of the 3.5 million servicemembers and veterans who
were exposed to burn pits and other airborne hazards, I implore you to
ensure that DOD follows recently enacted laws meant to increase
transparency and information sharing with those who have suffered
exposures, and to spare no effort in not only anticipating new hazards
our personnel may encounter, but advise them of their known risks ahead
of time so they and medical professionals are better equipped to
address emergent health impacts.
Again, thank you for allowing me to present testimony to this
Committee on behalf of IAVA.
Biography of Tom Porter
Tom Porter joined IAVA in 2015 and now leads IAVA's Washington, DC
government relations team in advocating for our Nation's veterans. He
has led successful campaigns to protect military and veterans education
benefits, combat suicide, address military toxic exposures like from
burn pits, and fill gaps in care for women veterans. Also a media
spokesman for IAVA, he has contributed to CNN, Fox News, NBC, ABC, PBS,
NPR, BBC (and local affiliates), Wall Street Journal, Washington Post,
POLITICO, and many others.
Prior to joining IAVA, Porter was Vice President at the energy firm
Morgan Meguire since 2004, representing energy utilities nationwide. He
was successful in achieving goals on behalf of a nationwide client base
through aggressive and bi-partisan advocacy before Congress and federal
agencies. He also served more than eight years on the staff of three
senior Members of Congress. Porter is a U.S. Navy Captain with Reserve
and Active service since 1996, including deployments to Afghanistan and
the Middle East.
Senator Gillibrand. Thank you. Mrs. Torres?
STATEMENT OF ROSIE TORRES, EXECUTIVE DIRECTOR,
BURN PITS 360
Mrs. Torres. Thank you, Chairwoman Gillibrand, Ranking
Member Tillis, and members of the subcommittee for today's
hearing and for this opportunity to testify.
It seems like yesterday when some Members of Congress
believed that the health risks of toxic exposures and burn pits
were based on anecdotal evidence. While we have data today that
shows otherwise, I am here to tell you personally about the
stories of the men and women who bravely defended our country,
exposed to toxic chemicals that for many cost them their life.
My story begins with my husband, Retired Captain, Le Roy
Torres, who served as a Texas State Trooper for 14 years and as
a soldier for 23 years before being medically retired. He
deployed to Balad, Iraq, from 2007 to 2008, where he was
exposed to the largest burn pit within the Operation Iraqi
Freedom theater of operations, which was the size of
approximately a football field. He lived and worked next to the
toxic plume of black smoke that infiltrated where they lived,
ate, and slept.
He returned home from war to face a health care system that
failed him, and an employer too afraid to understand an
uncommon war injury, resulting in termination of his law
enforcement career. As a result of these injustices, Le Roy
attempted to end his life in 2016.
Since returning from Iraq he has had over 400 medical
visits, until he was finally diagnosed with autoimmune disease,
toxic brain injury, and constrictive bronchiolitis following a
lung biopsy at Vanderbilt University. The VA and DOD refused to
recognize or diagnose these environmental injuries, often
misdiagnosing them as psychosomatic or dismissing them as
compensation-driven care-seeking. The more veterans we talk to,
the more we heard about stories like Le Roy's. This is why, 12
years ago, Le Roy and I co-founded Burn Pits 360, a nonprofit
that advocates for veterans, servicemembers, and families of
the fallen affected by toxic exposures.
We created a health registry of about 10,000 participants
to track their exposures, diseases, and deaths, working with
doctors like Dr. Szema. We then joined in Washington and
gathered with other families to pass the Airborne Hazards Open
Burn Pit Registry Act of 2013.
We have been too far too many funerals and counseled
countless wives, husbands, and children left alone by our
government's failure to treat our Nation's veterans. Burn Pits
360 has persevered through the years, despite the indifference
of the VA, DOD, and Congress. Instead of providing them with
treatment, early cancer diagnostics, and benefits, our
government spent the last years telling veterans there is no
evidence that inhaling toxic black smoke causes respiratory
illnesses and cancer that their stories are anecdotes and not
data, and that treating them is too costly. I cannot help but
wonder what is the cost of their lives and sacrifice?
So now more than ever we need to pass legislation that
addresses presumption. The time is well past due for the
President, the Department of Defense, Veteran Affairs to
acknowledge these injuries and disease as a direct result of
armed conflict or caused by an instrumentality of war. We are
asking for the Department of Defense and Veteran Affairs to
honor these injuries with compassionate common sense. This is
an invitation to begin the healing process for these families
who have lost loved ones to illness or death following the
environmental hardships of war.
Yet Le Roy's story is not the only one. Sergeant Thomas
Joseph Sullivan served with the United States Marines in Iraq.
He suffered from intestinal ulcerations and bleeding,
hypertension, respiratory disease, asthma, and liver disorder.
Tom died in 2009 at 30 years old.
Will Thompson served with the United States Army for 23
years and was deployed twice to Iraq. His doctors treated his
cough as allergies. He was later diagnosed with pneumonia,
treated with antibiotics, and sent home. Eventually he was
diagnosed with pulmonary fibrosis. After a lung biopsy he was
informed that he had titanium, magnesium, iron, and silica in
his lungs. Will underwent two transplants and passed away this
December at 50 years old.
Lieutenant Colonel Dan Brewer, CENTCOM Environmental
Officer, deployed to Afghanistan and warned his supervisors
about the health effects of the black fumes caused by burning
of waste and plastic at night.
Lastly, Isiah James served with the United States Army,
deployed to Iraq 2006 to 2008, 2008 to 2009, in Afghanistan,
2010 to 2011. Isiah says this. He is now suffering from lung
disease and is on supplemental oxygen. He says, ``It is my hope
you not only listen to the testimony but to hear it, to feel
it, to understand it, and most importantly, to act on it.
History is the ultimate judge, and we in this country have not
always done best by those who send in our stead. I believe it
was Churchill who said, 'Never has so much been owed to so few,
by so many.' How will you be judged and how will America and
the American people pay their debt?''
[The prepared statement of Mrs. Rosie Torres follows:]
Prepared Statement by Mrs. Rosie Torres
Thank you, Chair Gillibrand, Ranking Member Tillis and Members of
the Subcommittee for today's hearing and for this opportunity to
testify.
introduction
My husband Ret. Captain Le Roy Torres served as a State Trooper for
14 years before being discharged from State Service as a solider for 23
years before being medically retired. He deployed to Balad, Iraq from
2007 to 2008 where he was exposed to the largest burn pit within the
Operation Iraqi Freedom (OIF) theatre of operations. As a husband, a
father, grandfather and a first responder, he has been deprived of his
dignity, honor and health. He returned home from war to face a health
care system that failed him and an employer too afraid to understand an
uncommon war injury resulting in termination of his law enforcement
Career. As a result of this injustice Le Roy's USERRA case will be
heard before the United States Supreme Court next week on March 29,
2022. This is just one example of the bureaucratic inertia our former
and current military members are facing.
Since returning from Iraq he has had over 400 medical visits. In
November 2010 he was diagnosed with a debilitating lung disease
constrictive bronchiolitis following a lung biopsy at Vanderbilt
University. His doctors also diagnosed him with toxic brain injury due
to exposure to toxins, likely resulting from exposure to burn pits
exposures in Iraq. For years The VA and DOD have refused to recognize
or diagnose these environmental injuries, often misdiagnosing them as
psychosomatic or dismissing them as ``compensation driven care
seeking.''
For the past 12 years, Burn Pits 360, which Le Roy and I cofounded,
has been at the forefront of this issue, advocating for the families
and those battling life threatening illnesses. We established an
independent health registry tracking the illnesses and deaths for
present and former members of the United States military services,
particularly those with environmental and occupational illnesses. As
families we feel left behind without the support of a grateful Nation.
We have had to fight for that support everyday of our lives, while
dealing with illness or death of a loved one. We are asking for DOD and
VA to honor these injuries with compassionate common sense. This is an
invitation to begin the healing process for these families who have
lost loved ones to illness or death following the environmental
hardships of war.
Burn Pits 360 is a 501(c)(3) non-profit veterans organization is
headquartered in Robstown, Texas with the mission to advocate for
veterans, servicemembers, and families of the fallen affected by
deployment-related toxic exposures. Burn Pits 360 owns and manages a
health registry of about 10,000 participants that serves as a national
model.
Our impact includes the legislation creating the Airborne Hazards
and Open Burn Pit Registry (AHOBPR) signed into law in 2013 (P.L. 112-
260). The law also directed a longitudinal burn pits exposure study to
be jointly conducted by the U.S. Department of Veteran Affairs (VA) and
Department of Defense (DOD). We participated in the open comment period
for registry revisions submitted the VA Office of Public Health (OPH),
resulting in the addition of constrictive bronchiolitis to the
registry. We have presented our registry data to the National Academy
of Science committee created under the 2013 legislation, and we have
presented statements to the Defense Health Board and have participated
in every VA/DOD AHOBPR Burn Pit Symposium. Most recently our efforts
were successful in the passage of the Honoring Our Pact Act legislation
now making it's way over to the Senate.
The time is well past due for the President, Departments of Defense
and Veterans Affairs to acknowledge these injuries and disease as a
direct result of Armed conflict or caused by an instrumentality of war.
Burn Pits Health Consequences and Impact
Numerous military bases in the Operations Iraqi Freedom (OIF) and
Enduring Freedom (OEF) theatres of operation produced several tons to
several hundred tons of solid waste per day. Open-air burn pits were
the primary waste disposal method during the majority of the duration
of these wars in Iraq and Afghanistan. This involved the burning of
plastics, body parts, expired pharmaceutical drugs, chemicals from
paint and solvents, unexploded ordinance, petroleum, and according to
some reports, nuclear and biological waste.
Additionally, some of the burn pits were reportedly built on top of
soil contaminated by chemical war agents. Due to the unacceptable risk
posed by these burn pits to our servicemembers, their use was
eventually mostly banned, except under narrow circumstances, in 2010.
Tens of thousands of servicemembers have been exposed to toxic
chemicals and micro fine, highly respirable and dangerous particulate
matter from burns pits and they continue to suffer serious, disabling
health consequences upon their return.
A defense contractor stationed at Al-Taqaddum in Iraq from 2006 to
2007 described the impact of burn pits and their health effect in a
November 2014 news story: ``Burn pit smoke would encircle the entire
military base in an enormous dark ring that settled to the ground after
darkfall . . . . A lot of people got rare cancers and died. Any exposed
skin and mucous membranes, as experienced by many of us, felt on fire,
and burning. Many of us developed shortness of breath.''cancers and
died. Any exposed skin and mucous membranes, as experienced by many of
us, felt on fire, and burning. Many of us developed shortness of
breath.''cancers and died. Any exposed skin and mucous membranes, as
experienced by many of us, felt on fire, and burning. Many of us
developed shortness of breath.'' \1\
---------------------------------------------------------------------------
\1\ Elizabeth Hilpert, quoted by Dan Sagalyn, ``Photo essay: The
burn pits of Iraq and Afghanistan,'' November 17, 2014, PBS News Hour.
https://www.pbs.org/newshour/world/photo-essay-burn-pits-iraq-
afghanistan
---------------------------------------------------------------------------
The wars in Iraq and Afghanistan exposed United States service
women and men to an unprecedented array of airborne health hazards
including from open-air burning in vast burn pits; shock waves and
toxic particulates from improvised explosive devices (IEDs), including
vehicle-borne improvised explosive devices (VBIED) and those containing
chemical warfare agents; and hazardous microfine sand particles. \2\
Servicemembers with new-onset, post-deployment respiratory symptoms
from these hazards are being labeled as having Iraq/Afghanistan War-
Lung Injury (IAW-LI). \3\
---------------------------------------------------------------------------
\2\ Szema, Anthony et al, ``Iraq dust is respirable, sharp, and
metal-laden and induces lung
inflammation with fibrosis in mice via IL-2 upregulation and depletion
of regulatory T cells,'' J Occup Environ Med. 2014 Mar;56(3):243-51.
https://dx.doi.org/10.1097/JOM. 000000000 0000119
\3\ Szema, Anthony et al, ``Proposed Iraq/Afghanistan War-Lung
Injury (IAW-LI) Clinical Practice Recommendations: National Academy of
Sciences' Burn Pits Workshop,'' Am J Mens Health, 2017 Nov; 11(6):
1653-1663. https://dx.doi.org/10.1177 percent2F1557988315619005
---------------------------------------------------------------------------
Here is some of what we now know:
Air sampling data indicate that smoke from these burn
pits contained chemicals associated with cancers, lung diseases,
cardiovascular disease, kidney disease, neurological disorders, and
more.
The Burn Pits 360 national registry confirms that the
array of devastating health conditions being suffered by exposed
veterans include pulmonary diseases, rare forms of cancer, and many
unexplained diseases and symptoms.
The VA's national registry, though it contains over
260,000 registrants, fails to account for the true impact of burn pits
exposure by underperforming participation rates, failing to track
comorbid conditions that develop following initial registration, and
failing to allow for the entry of cause of death information.
It is a national failure to adequately prevent, diagnose,
treat, and compensate burn pits-exposed Active Duty troops and
veterans.
There are a number of crucial issues related to burn pit exposure
and IAW-LI that we strongly believe this Committee should investigate
and which require the focused attention of the DOD.
The current lack of clear understanding of the health impacts of
theses exposure should not circumvent our national obligation to assist
every affected military servicemember and veteran. In particular, we
would highlight the following important focus areas:
1. Improving the burn pit registry so that it can be an effective
research tool for monitoring and identifying the health consequences of
burn pit exposure;
2. Improving VA compensation claims for burn pit Active
servicemembers, including establishing presumption of service-
connection for debilitating symptoms and diseases that have been linked
to burn pit exposure;
3. Conducting more and better research into the health
consequences of burn pits and to develop effective treatments for them;
4. Establishing evidence-based clinical practice guidelines with
effective screening and treatment protocols for physicians caring for
veterans exposed to burn pits, and a specialized care program for IAW-
LI and comorbid conditions;
5. Disability needs to be based on injury or disease as a direct
result of Armed Conflict or caused by an instrumentality of war.
6. Adopt Force Protective Measures, Institute measures to equip
personnel deployed to high risk areas with masks or other devices to
protect against toxic airborne exposures.
7. Improving collection of servicemembers health records of
exposure.
Testimonies
CPT (Ret.) Le Roy Torres, Co-founder, Burn Pits 360 Veterans
Organization.
``Many servicemembers have returned from the Iraq and Afghanistan
wars with a multitude of illnesses that are invisible and are
associated with burn pit exposure and may remain dormant for years. As
our motto says, ``the war that followed us home'' has become a reality
and dreadful journey for many veterans. I for one, these invisible
wounds from toxic exposure have taken a toll on my health and cost me
my military and civilian career as a Texas state trooper. As citizen-
soldiers, we deserve to keep our jobs when we return from serving our
Nation overseas if we return with limitations. We honored our oath to
this Nation; We should not have to bear the burden alone due to
exposure to an instrumentality of war.''
Sergeant Thomas Joseph Sullivan, U.S. Marine, Tom died 2009, 30
yrs old
Tom went to Iraq in top health, assigned to an elite Force
Reconnaissance unit. He reported on his post deployment health form
that among other things he was exposed to ever present dust, fumes from
local chemical plants and burning feces and that while deployed he
experienced rectal bleeding and congestion. After he
returned his medical problems multiplied in number and severity and
included intestinal ulcerations and bleeding, hypertension, respiratory
diseases, sleep apnea and asthma and a liver disorder. He suffered from
extreme and diffuse pain and swelling.
Tom had what the military medical system sometimes refers to as
chronic multi-symptom illness, and sometimes as medically unexplained
symptoms (MUPS). His health declined despite several months of
treatment. At this critical juncture, he asked for a fresh, multi-
disciplinary reassessment. He was sent to a clinic that specializes in
MUPS and was offered only a program of exercise that was precluded by
his pain and psychological counseling. Six months later he died. Tom's
principal physician later told us he had believed Tom had a somatoform
disorder (i.e., psychological illnesses).1 The Virginia Medical
Examiner's autopsy report found previously undetected heart damage that
was designated as a contributing cause of his death. It also found that
the combination of prescribed medications (including one after Tom
died, his widow and I requested physician emails discussing the
somatoform disorder which had been withheld from Tom's health records.
Walter Reed Army Medical Hospital denied the request: No written record
of the emails had been retained and they had been deleted from the
computer system, and it would cost $500,000 to search digital records
to retrieve them.
At the time Tom was deployed and upon his return the military
medical system was aware of environmental health hazards in theater and
the symptoms and illnesses they might produce. If warnings were issued
to our troops before, during or after deployment, I have seen no record
of them. The airborne hazards from dust and fumes could have been
mitigated to a large extent by issuing simple N395 dust masks that can
be purchased in bulk for a couple of dollars. Indeed, recommendations
had been made to the military to take such measures, but were ignored.
Despite Tom's failing health and his exposure history, his
physicians did not tell him that many airborne troops at Fort Campbell
who had served in Iraq and Afghanistan had been diagnosed with a rare
lung disease; or that particulate matter to which he was exposed in
Iraq far exceeded USG standards and was carrying toxic metals,
bacteria, viruses and fungi, including toxins found naturally, plus
those added by USG burn pits and local industrial pollution. He was
basically treated at though he never had left the United States, rather
than as a person who might be suffering from a toxic wound received in
a war zone.
The symptoms Tom exhibited, as did those by the Airborne soldiers
at Ft. Campbell, and many thousands more who have served in Iraq and
Afghanistan, are consistent with toxic exposure of one or more kinds.
Yet, Tom's health care was apparently not informed by the body of
knowledge available to the military medicine at the time. Apparently
baffled by his symptoms, medical judgment defaulted to the notion that
they were psychosomatic. This is the same discredited explanation that
had previously been ascribed to Gulf War Illnesses.
William Thompson, SSG, U.S. Army (Ret.) Will Passed away 12/2021
My name is retired SSG William Thompson. I served 23 years, 3
months and 11 days in the United States Army and WVARNG. I have
deployed twice with the WVARNG to Iraq. During my last deployment, I
was stationed at Camp Stryker at the Victory complex. My symptoms of
frequent coughing started around September of 2009 while in Iraq, in
which my doctors and PA's treated me for what they thought were
allergies. I returned to Fort Stewart, GA and after I mentioned to the
doctors, I was having frequent cough, they did a CXR that revealed
bilateral pneumonia. They treated me with antibiotics and sent me home
to WV to follow up with my PCP in one week. After a week, I followed up
with my PCP Dr. Remines, and he discovered after more testing that I
had pulmonary fibrosis with nodules and stated that my lungs looked
like an ``80-year-old coal miners' lungs''. He referred me to Walter
Reed Army medical center pulmonary department where I was treated by
Dr. Jacob Collins for 6 months. He admitted me to the Warrior
Transition unit at Walter Reed and after 6 months of testing which
included an open lung biopsy, I was informed that I had titanium,
magnesium and iron in addition to silica in my lungs. They diagnosed me
with Hypersensitivity Pneumonitis and Pulmonary Fibrosis. I gained 60
lbs. from the high amounts of steroids I was on daily. Because my lung
disease was chronic, I was referred to Inova Fairfax Hospital by Walter
Reed and was told I would most likely need a lung transplant in the
future. I have been seen by Inova Fairfax Hospital Lung Transplant
Clinic from February 2011 to the present time.
During that time, I have been on oxygen as high as 10 liters
continuously. On June 6, 2012, I received a double lung transplant,
after 2 months of follow ups, I was able to return home to start
pulmonary rehab. The first year was a good year. I took all precautions
and followed all the orders that were instructed by my doctors. Despite
this, over the next 3 years, I went through periods of lung rejection
and infections and decreased oxygen levels. I was back on oxygen again.
On March 9, 2016, I underwent another double lung transplant. Lung
transplants unfortunately are more susceptible to complications than
other organ transplants since the lungs are exposed to everything from
the environment.
My life and my family's life have changed since I returned home in
2010. I have to wear a mask in highly populated areas. I know wearing a
mask is typical these days, but I have been wearing one since 2012.
It's hard to hang out with my kids only to tell them ``I can't do
that''.
``Dad, let's go skiing'' . . . sorry kids, I can't' do that
``Dad let's go swimming'' . . . sorry kids, I can't do that
``Dad, can you give me a piggyback ride?'' Sorry Ava, I can't do that
``Dad, let's go fishing'' Sorry Ethan, I can't do that because of the
bacteria on fish ``Dad let's go to the beach'' Sorry kids, I can't do
that because of the bacteria in the water and the sun with my
transplant medications makes me more prone to skin cancers.
Speaking of skin cancers, I am currently battling Trigeminal
Neuralgia after having a skin cancer removed from my left cheek that
aggravated my trigeminal nerve. This is a very painful, debilitating
condition that is also known as the ``suicide disease'' and is known to
be one of the most painful disorders known to medicine. It causes
sudden, shock -like pain in my face that lasts from minutes to hours at
a time. Because of this disorder, I have added numerous medications to
my previously very large daily pill regimen.
I don't feel like a man because my wife has had to take that role
from me. There are so many things that I can no longer do.
I am a warrior of the United States of America. I gave my lungs for
my country. The toxins in the air from burn pits and the dust in Iraq
has changed my life. I am glad to be alive and home when so many did
not make it home. My illness and injuries are different. I have heard
so many times from the VA ``we don't know how to treat you'', or ``you
don't qualify or fit into our parameters for benefits''. I have been
denied TSGLI because the army does not think having a lung transplant
is a ``traumatic event''. Luckily, we found the group, Semper Fi fund/
America's fund who works with veterans and provided the funds to make
my bathroom ADA accessible. Since then, the VA has helped me with one
housing HISA grant, but only after being denied several times. My
injuries are illnesses are different from other more common injuries
from Iraq and because of that it took the VA 3 years to provide me with
an air purifier in my home to keep my home free of allergens and dust.
They also denied help in removing carpet in my home that was instructed
by my doctors, so we had to pay for this ourselves. We have also taken
out a loan to build a workout area in my home where I can work out and
continue my pulmonary rehab during times of my illness or times when
cold or flu season is at its peak. Although, I was 100 percent service
connected through the Army and VA, I don't qualify to receive my
retirement until age 60 because my injuries were not ``combat
related''. I may not live to be age 60--I turn 50 this year.
Every day for me is a battle I continue to fight. I still have to
battle infections and try to keep my body healthy from lung rejection.
I still have to fight secondary problems related to my transplant.
Hopefully, after hearing my story, it will bring awareness for not only
me but others who are battling the same or similar injuries related to
burn pit exposures from Iraq or Afghanistan. Thank you allowing me to
share my story.
Testimony from LTC Dan Brewer, CENTCOM, CCJ4-E
CENTCOM Environmental Officer
At approximately 1745 hours, 30 September 09, LTC Daniel Brewer,
CENTCOM CCJ4-Environmental Officer (deployed forward to Afghanistan),
Mr. William Porter, Afghanistan Environmental Manger for RC-East
(Bagram), and Katherine ``Kat'' Blesi, Afghan Engineer District Realty
Specialist for RC-East (Bagram) noticed a very large column of black
smoke covering the sky when coming out of the North DEFC. We
immediately proceeded to investigate, driving toward the source of the
plume. As we got closer, we found the smoke to be coming from the
Bagram Solid Waste (SW) yard. When we got within a mile of the yard, we
could also see a huge fire burning.
After arriving at the SW yard we were met by Mr. William Powell,
KBR General Foreman for Solid Waste, and one of his assistants (name)
who told us they burn ``on the hill'' every night about this time. When
asked what they were burning Mr. Powell said it was items they were
told to burn (by the military) because they were sensitive items and
could not be recycled. I asked him who from the military told him to
burn those ``sensitive items'' and asked him what those items were.''.
Mr. Powell couldn't answer either question, but said it was a lot of
plastic. I asked him why they were burning them at night, and he said
they couldn't burn during the day because of the ``birds''. I told him
it was wrong to be burning those items due to the health risks it was
causing.
Statement from Geoff Dardia, Special Forces, Task Force Dagger
Consider areas that Special Operations deploy to that are not
common knowledge and the fact that medical providers are not aware of
the amount of toxins SOF soldiers are exposed to from ammunition and
explosives both deployed and in the garrison environment. There is no
type of screening process in place to check servicemembers post
deployment. Special operations soldiers shoot more ammunition in one
day than an entire infantry brigade shoots in an entire year. The
volume of exposure in SOF areas are not being tracked.
Isiah James,
Senior Communications and Policy Director, The Black Veterans
Project.
Advocate, Burn Pits 360.
To the distinguished Members of this Committee, thank you for
taking the time to address this most pressing and critical of issues
laid out before you today. Many of you may have members of your family
that have served and surely you have numerous constituents who have
worn the uniform. Knowing that I, have the utmost confidence that my
words here today will not fall on deaf ears.
As our Nation, and the world moreover is glued to our tv's looking
at the horrors of war as the now ravage Europe, I want you to think
about that knowing that American service men and woman had to endure
these trials and tribulations for some twenty years. Thousands of young
men and woman came back home missing limbs, ravaged with the wounds and
scars of battle and they were given the best care America could muster.
Yet those who came back home with the invisible wounds, those wounds
sitting there, waiting like a chemical time-bomb primed to detonate
months and years after they doffed their uniform; I'm of course
referring to the tens of thousands of servicemembers exposed to toxic
but pits.
Today you are going to hear gut-wrenching testimony from subject
matter experts of the effects of such exposure. It is my hope you not
only listen to the testimony but to hear it. To feel it. To understand
it, and most importantly to act on it. History is the ultimate judge
and we in this country have not always done best by those who we send
in our stead. I believe it was Churchill who said: never has so much
been owed to so few, by so many.
How will you be judge and how will America and the American people
pay their debt.
Senator Gillibrand. Thank you. Mr. Patterson?
STATEMENT OF STEVEN PATTERSON, FORMER ENVIRONMENTAL SCIENCE
OFFICER, COMBINED JOINT TASK FORCE 101 HEADQUARTERS,
AFGHANISTAN, 2008-2009
Mr. Patterson. Senators, thank you for this opportunity. I
am Steven Patterson, a retired environmental science and
engineering officer. This falls into the larger preventive
medicine community that was mentioned earlier.
I am here today to assist you with your understand of burn
pits, environmental health exposures, and how those were
documented. Primarily, I can speak to the time of 2008 to 2009,
when I was a senior environmental science officer for Combined
Joint Task Force 101 while it was the headquarters for
Afghanistan. In this position, I traveled the Nation
extensively and saw most of the locations where U.S. Forces
were deployed. My job was to conserve the fighting force and
identify environmental health exposures.
The deployed environment is very challenging, and it is
very difficult to document a person's exposure in such a
setting. The equipment to identify and quantify exposures is
often lacking as are trained personnel, especially in remote
locations. This is made more difficult as we often have
exposures which one would not anticipate, as well as the
challenge of accurately placing a certain person in a location
at a given time. This is made worse when attempting to look
back 10 or 20 years as camp names often changed and the
personnel system does not operate down to the person.
Almost all of the locations I visited had burn pits
operating at that time, and few, if any, separated their waste
before burning it, so many contained pressure treated lumber,
galvanized metal, significant quantities of plastics, and
lithium batteries. These were not pits, but simply low-lying
areas where the waste was thrown and burned. Typically, they
smoldered a great deal which is important as the combustion is
not complete, more toxic compounds may form, and these toxins
will not be lifted away so stay in or near the air around the
camp.
Most of these burn pits were within the perimeter fence for
security reasons, or very close to the perimeter if outside of
the camp. Most of the small camps had few, if any, air samples
taken at them due to limited personnel, equipment,
transportation challenges, and time.
We had roughly 20 people to attempt to document the
environmental exposures of over 37,000 people spread over an
area roughly the size of Texas. However, I do not think that
more environmental health people are the ideal solution.
The limited environmental health data, mostly air samples
with some soil and water samples, cannot be linked to a person
but only to a location, and even if the person can confirm that
they were at that location it does not mean that they had that
exposure. Their exposures could have been much worse or much
better than that sample indicated.
The DOD has this responsibility and must address it as
industry likely will not do so as they do not face these
particular challenges. We have struggled in this space since
Desert Storm, and we must look at different options moving
forward. We must leverage technology and address policy issues
to fix these gaps.
Some possible options to consider:
One, creation of a Joint Program Executive Office in order
to focus the research and funding on environmental health
surveillance while also providing a central location to hold
responsible in the future.
Two, silicone brackets could be provided to servicemembers
to track their exposures, as mentioned earlier. These have been
shown to capture more than 1,500 different chemical compounds
and would allow us to mitigate exposures much sooner while also
providing the servicemember with personal exposure data.
Three, research and build a replacement for the silicone
bracelet which would provide near real-time information on
exposures and dose for a servicemember.
Four, create a repository of frozen soil samples from each
deployment location so they may be tested in the future as
needed when new concerns are identified.
Five, improve the personnel reporting system so that each
individual can be located rather than their unit headquarters
which may be hundreds of miles away from them. This will allow
for individual exposures to be more accurately documented.
Six, remote sensing should be researched to address gaps in
environmental surveillance. This will be key for small teams
operating in remote areas or dense urban environments which may
never have an environmental health professional visit them.
Seven, further research biomarker monitoring to document
exposures a person had during their deployment or over their
military career.
Finally, eight, educate leaders on the hazards of toxic
exposures and hold them responsible if they needlessly expose
their people.
Thank you for your time. I am open to any questions.
[The prepared statement of Mr. Steven Patterson follows:]
Prepared Statement by Mr. Steven Patterson
I am Steven Patterson, a retired Army Environmental Science and
Engineering officer.
I am here today to assist with your understanding of burn pits,
environmental health exposures, and how those were documented.
Primarily, I can speak to the time of 2008 to 2009 when I was the
senior Environmental Science officer for CJTF-101 while it was the
headquarters for Afghanistan. In this position I traveled the Nation
extensively and saw most locations where U.S. Forces were deployed. My
job was to help conserve the fighting force and identify environmental
health exposures.
The deployed environment is very challenging and it is very
difficult to document a person's exposure in such a setting. The
equipment to identify and quantify exposures is often lacking as are
trained personnel, especially in remote locations. This is made more
difficult as we often have exposures which one would not anticipate as
well as the challenge of accurately placing a certain person in a
location at a given time. This is made worse when attempting to look
back 10 or 20 years as camp names often changed and the personnel
system doesn't operate down to the person.
Almost all of the locations I visited had burn pits operating at
that time and few, if any, separated their waste before burning it so
many contained pressure treated lumber, galvanized metal, significant
quantities of plastics, and lithium batteries. These were not pits, but
simply low lying areas where the waste was thrown and burned.
Typically, they smoldered a great deal which is important as the
combustion is not complete, more toxic compounds may form, and these
toxins will not be lifted away so stay in or near the air around the
camp.
Many of these burn pits were within the perimeter fence for
security reasons, or very close to the perimeter if outside of the
camp. Most of the small camps had few, if any, air samples taken at
them due to limited personnel, equipment, transportation challenges,
and time.
We had about 20 people to attempt to document the environmental
exposures of roughly 37,000 people spread over an area roughly the size
of Texas. However, I do not think that more environmental health people
are the ideal solution.
The limited environmental health data; mostly air samples with some
soil and water samples cannot be linked to a person but only to a
location, and even if the person can confirm that they were at that
location it does not mean that they had that exposure. Their exposures
could have been much less or much more than that sample indicated.
The DOD has this responsibility and must address it as industry
likely will not as they do not face these particular challenges. We
have struggled in this space since Desert Storm and we must look at
different options moving forward. We must leverage technology and
address policy issues to fix these gaps.
Some possible options to consider:
1. Creation of a Joint Program Executive Office in order to focus
the research and funding on environmental health surveillance while
also providing a central location to hold responsible in the future.
2. Silicone brackets could be provided to servicemembers to track
their exposures, these have been shown to capture more than 1,500
different chemicals and would allow us to mitigate exposures much
sooner while also providing the servicemember with personal exposure
data.
3. Research and build a replacement for the silicone bracelet
which would provide near real time information on exposures and dose
for a servicemember.
4. Create a repository of frozen soil samples from each deployment
location so they can be tested in the future as needed when new
concerns are identified.
5. Improve the personnel reporting system so that each individual
can be located rather than their unit headquarters which may be 100s of
miles away. This will allow for individual exposures to be more
accurately documented.
6. Remote sensing should be researched to address gaps in
environmental surveillance. This will be key for small teams operating
in remote areas or dense urban environments which may never have an
environmental health professional visit them.
7. Further research biomarker monitoring to document exposures a
person had during a deployment or over their military career.
8. Educate leaders on the hazards of toxic exposures and hold them
responsible if they needlessly expose their people.
Senator Gillibrand. Thank you. Senator Tillis?
Senator Tillis. Thank you all for being here. I guess you
heard the testimony--I think most of you were in the room--
during the first panel. It sounds as if there is consensus on
one of the questions that I brought up, on individualized
monitoring and sensors. But speaking for Active Duty, Mrs.
Torres, I do a lot of work, I serve on the VA Committee. We
have got a lot of work to do and we are making progress, and
again, I want to give Senator Gillibrand credit for focusing on
that issue. We are going to make more progress there. I am
sorry for the situation with your husband and for the others
that you mentioned.
But with respect to what we need to do better upstream, how
would you judge the DOD in making a priority, the priorities
that you all have delineated in your opening comments? Where
are they falling short?
Mrs. Torres. My team applied for a congressionally directed
medical research program grant, funded by the DOD, recently,
months ago. We got a great score. This was a for a monitor the
size of a beeper that a soldier could wear, that would not only
measure particulate matter but even sarin gas, specifically,
and gunshot sounds. Despite a good score they said there are no
funds. So I do not know why they are asking us to apply for
grants if there is no money.
Senator Tillis. Well, that is a question we can get to the
bottom of.
Mr. Porter. Thank you, Senator. One of the biggest things,
and I mentioned it in the testimony, but one of the biggest
problems is we have experienced a big lack of transparency from
Federal agencies on what people were exposed to on their
deployments. That is the big thing, and I think the ILER is
meant to tackle that. It is just a matter of, is it going to be
useful to the servicemember and to the veteran. That is key.
Senator Tillis. You also mentioned the idea that the
registry is available, but I, for one, think that we should be
in an opt-out position, that everybody should be registered in
the registry, and if they want to explicitly opt out I supposed
they should, but we should probably flip the script on that.
Would you agree?
Mr. Porter. Right. The Burn Pit Registry, what the law
requires is for them to be entered into it unless they opt not
to. So it is not mandatory if you do not want to be in the
registry, but the laws that if somebody is exposed or they are
stationed next to a burn pit, then they should be entered into
the registry.
Mrs. Torres. I agree. I mean, the Burn Pit Registry still
falls short in so many ways. It is basically just self-reported
data that you could print out and carry around. But it is
important that everyone be a participant of that effort. You
know, they do not track mortality, which is, I think, one area
that we have talked about for years, Dr. Szema. But I agree,
Senator Tillis, that that should be mandated.
Senator Tillis. Mr. Patterson?
Mr. Patterson. Senator, there are so many challenges in
this space. The previous individuals talked that so much of it
is self-reported. So a 20-year-old individual returns from
overseas, and you ask him what happened to him over 15 months.
Not to mention the fact that that individual, they are not
going to be able to say, ``I was exposed to TCE or benzene or
toluene.'' Just, ``Some bad stuff happened to me. There was a
lot of smoke.'' They cannot say anything that is going to help
that clinician when they end up in the VA system. So so much of
what is being done now is just not terribly effective.
Senator Tillis. That is why I get to the need for us to get
down to the atomic level sooner rather than later. That is the
only way we are really going to be able to capture it, and then
have the level of specificity with respect to the specific
exposures. So I agree with you all.
We are coming up on the end of a vote. I thank you all for
being here. I also appreciate your opening testimony. There
were a lot of priorities put in there, and they will be
instructive to me as we move forward. Thank you.
Thank you, Madam Chair.
Senator Gillibrand. Thank you. Mrs. Torres, first of all I
want to thank you for your advocacy on behalf servicemembers,
veterans, and their families who have suffered debilitating
injuries and effects of burn pits. What is the top challenge
that you hear from soldiers when they return from deployment
about accessing treatment?
Mrs. Torres. Well first of all, Senator, thank you for
having me. Lots of challenges. That question just brings up so
many ideas in my mind of things that we have tracked through
our own private registry, and off the top of my head it is
access to health care monitoring, specialized health care, both
on the DOD and VA side, but primarily DOD. For those Active
servicemembers, for those reservists it is a challenge when
they do not have trained occupational medicine doctors
assessing these underlying issues.
Then secondly is filing for presumption for these illnesses
that are underlying. So if you do not have the specialized
health care, how can they properly transition them through the
compensation and disability process?
Senator Gillibrand. Right. Thank you. What information and
resources would be most helpful to the servicemembers you work
with when they return from deployment to ensure they are
getting the screening and treatment they need?
Mrs. Torres. I think, you know, definitely mandating that
the clinicians be trained, and I think Dr. Szema can help me
here, but absolutely having every clinician, every nurse
trained in the area of airborne hazards, documenting in the
record, you know, in the electronic health record on the VA and
the DOD side, that they are identified as having undergone some
type of exposure.
To say the least, I have had this conversation recently
with many people about even just something as small as signage,
right? Like during the World Trade Center, there was
communication and outreach and signage on ``if you are
experiencing these issues.'' People are having to access care
through people like Dr. Szema, and they have to fly to New York
and fly to Vanderbilt and exhaust their life savings, like our
family did. That should not be happening in America, and so we
need to start now.
Senator Gillibrand. Thank you very much.
Mr. Porter, thank you for sharing the survey results of
your members. Why do you think only 59 percent of IAVA members
are registered in the Burn Pits Registry? Dr. Rauch testified
as to some of the steps the DOD is taking to increase
participation in the registry. Have you seen an increase in
those registered over the years among your members, and what do
you think can be done to better encourage more servicemembers
and veterans to participate?
Mr. Porter. Thank you for the question. This came up when
we developed the Burn Pits Accountability Act a few years ago,
because if you look on the VA website it has a running total of
those that are registered in it. At the time when we looked at
it, back in 2017, there were only 140,000 entries in the
registry. I think it is probably double that now. I have not
looked recently. But it was only 140,000, and that is out of,
again, VA's estimate is as many as 3.5 million have been
exposed. So for only 140,000, that presented a big challenge.
I think that the main problem with that, the reason for
that, is because hardly anybody knows about the registry. So
through the passage of that bill we talked about it a lot, and
we put out a lot of social media on that, and we have also
encouraged the VA to do more about that, to get the word out to
veterans that this registry is here and then why somebody
should be in it. You get, I understand, a free health exam if
you are in the system. But again, it is not qualifying somebody
for presumption. I think there is a misunderstanding there too.
Veterans should apply for their disability, and they are
getting turned down, about three-quarters of the people that
apply.
Senator Gillibrand. You testified that if the ILER system
is done right servicemembers and veterans will have significant
transparency into their exposure. What does ``done right'' mean
to you, and what are the critical components of ILER that must
be implemented to make a difference in the care servicemembers
and veterans receive?
Mr. Porter. Well, what ``right'' looks like is if somebody
was deployed to Balad, Iraq, in 2006, then that ILER should be
able to give them the data from what they were probably exposed
to in 2006 in Balad. Same thing with me. I traveled around
Afghanistan all over the place, so it really can't pinpoint to
one location. So that just shows how complex it was. So I
traveled around the whole country, frequently, so it would be
harder for that.
But again, it should specify what you were exposed to
during your deployment, during a set period of time.
Senator Gillibrand. Now I am going to turn it over to
Senator Warren, and she is going to chair the meeting while I
go vote.
Senator Warren. [Presiding.] So thank you. We are tag-
teaming here. I voted early so that I could be here while the
chairwoman goes to vote. I want to say publicly a big thank you
to the chairwoman for holding this hearing. I think it is
really important. I think it is important that this committee
look at the real costs of war, including where the Department
of Defense failed to take steps that were necessary to prevent
exposing members of the military to toxic chemicals. I know
that many of our witnesses on this panel have been fighting for
over a decade for DOD and the VA to recognize how burn pit
exposure has had devastating effects on servicemembers' lives.
I know that there is some debate over the data, but it is
just common sense that these toxins would cause significant
problems to human beings. It is important for DOD to continue
to study this issue, to improve our understanding of the
science, but we cannot keep waiting for action. We need to take
care of our veterans now--not later, now.
I know that the focus of today's hearing is DOD's role in
determining eligibility for care, not the VA's, but we also
have to consider the toll of this entire process on families.
So Mrs. Torres, if you do not mind, I would like to be able to
ask you about your experiences. I read your testimony. I
understand about how hard you have had to fight, how long you
have had to fight to get the care that your husband deserves
and that other veterans deserve. So if I can let me just ask
you a little bit about how this process makes your family feel.
Mrs. Torres. Thank you so much for that question. It has
been a journey, a hellish journey, of delay and deny, not just
for myself, the Torres family, but for thousands, possibly
millions of families. I know for my husband, being stripped of
his integrity and dignity, you know, losing his job, being on
the brink of foreclosure, repossession of cars, and you ask
yourself, how did we get here and how is this happening in
America's backyard, it feels as if the Nation has turned its
back when you are attempting to just access care. We attempted
to access care from both DOD and VA health care institutions,
and throughout those 10 years it was always an excuse of there
is no science, there is no proof.
So myself, including, I know, many, many families, maybe to
include yours, Tom, is that we have to exhaust our life savings
just to access doctors like Dr. Anthony Szema, like Dr. Robert
Miller, like the doctors over at National Jewish. Being away
from our children that is time lost that will never get back,
and so not only does it impact the veteran and spouse but the
children.
To this day, to finally see some momentum, as we are seeing
now, it really gives us hope.
Senator Warren. Well I am glad to hear you end that on
hope, but when you say you feel as if our government, our
country, has turned its back on you and your family and
thousands, maybe millions of families in the same position, no
veteran should feel that way, and no family of a veteran should
feel that way.
You have done a tremendous amount of advocacy related to
changing the rules for how veterans must prove they were
impacted by burn pits in order to get care. I support you in
your work on this. I know it is a hard and lonely journey, but
you have done remarkable work here.
So let me see if I can turn this around just a little bit.
Mrs. Torres, what would it mean to you and other veterans'
families if the rules were changed so that the DOD and the VA
believed veterans when they said their health was harmed by
burn pits rather than making them jump through so many hoops?
Mrs. Torres. Well, it would remove the burden of proof of
us having to be our own lawyers, our own researchers, our own--
all of those things that we have become, right? We have sort of
mobilized and congregated online, all sharing that common
denominator of delay and deny. So to finally see historic
legislation passed so that we do not have to be all those
things, so that the Gold Star spouses that call us weekly,
expressing how heart-wrenching it is for them to spend the last
moments of their loved ones' life gathering buddy statements
and evidence when they should be holding the hand and embracing
their loved one, it would mean everything to us and to those
families that are still struggling to this day, and for those
still waiting on an answer from the VA.
Senator Warren. Well, as I said, I commend you for your
advocacy work here. It at least helps us start to move in the
right direction. I appreciate that making a change like this is
not inexpensive. There is a lot of money at stake here. I also
understand it is not all in the jurisdiction of this committee.
But it is urgent that we treat families, we treat those who are
injured without delay. We cannot allow veterans to wait another
minute for health care, and so I hope that the work we do here
today will help put more momentum behind change.
You know, this committee regularly advocates for spending
on weapons that do not work or weapons that are not needed at
all. It is inexcusable to claim that we need to balance the
budget on the backs of veterans and their families who have
been injured. So I hope that what comes out of our work today
is that we can give a stronger push on that.
If I can, I have got a few more questions here, questions
that the chair also wanted me to ask. Mr. Patterson, if I could
ask you about the advances in technology that have been made,
and can be made to improve the way that troops' toxic exposure
can be documented. Could you say a bit about that please?
Mr. Patterson. Thank you, Senator. As far as advances since
Desert Storm, sadly it has not been very significant. We
replaced the miniVOL with another type of particulate matter
sampler, but there are still significant challenges. Those
samplers simply capture the particulate matter that is in the
air, and then you can send it to a lab, and many months later
get a report back of what was possibly in that sample.
The downside of that is any volatile organic compounds are
not going to be in that sample, because they will have cooked
off in the transportation and those months for you to get the
sample back. So the progress has been extremely slow and
extremely challenging, and I am just looking at my time in from
Desert Storm to Afghanistan.
I made some recommendations in my testimony. I believe that
the biomarkers have some significant capabilities with them.
The silicone bracelets, I think, is an excellent idea, because
then we would be able to know much sooner. For instance, in
Afghanistan we had formaldehyde-treated lumber from China that
we were using to build the small buildings that the soldiers
slept in. I had no reason to expect to find formaldehyde in a
pristine river valley in Afghanistan. Why is that there? I have
no reasons to go look for that.
If we had had those silicone bracelets on those individuals
we could have had them back, and there is time to this. But I
would have known quickly rather than a year or two later, what
is this, and then we could have mitigated it and I could have
protected the next group of soldiers that went in there.
The remote sensing that I mentioned, I believe is very key
moving forward. If we are going to do dispersed operations with
small groups, there is a lot of atmospheric analysis that can
be done with satellite imagery. It is a bit of an immature
space, but if you are talking special operations units that are
very small, they are never going to have a preventive medicine
person visit them. So that would give you some idea.
I believe the problem with all of these things is they are
not perfect, but they will further the science significantly,
and we have been pushing too much for perfect rather than
taking some reasonable steps forward.
Senator Warren. Just so I can get the comparison here, can
you say a little bit about when you were in Afghanistan in 2008
and 2009, how was an individual's exposure to a burn pit
documented?
Mr. Patterson. Senator, some of them were not documented at
all, which is a very frustrating point for me. We were
operating down in the small FOBs where it might have been a
platoon on a FOB, so 50 people, maybe 100 individuals. With a
staff of approximately 20 people there was no way that I could
get them out there to do that surveillance, which should have
been done weekly. Ideally you want to do it once a week,
rotating, so you never repeat it on the same weekday.
So some of those FOBS, I would grab a soil sample, because
that was all that I could do. Those air monitors take 24 hours
to capture a sample properly. If you just go and take a grab,
it could be very high or very low. You need the coverage over
24 hours.
So a lot of them, there is probably little to no data in
the DOEHRS system, which was mentioned earlier, to be able to
address that soldier's concerns. The larger compounds fared
better. But even then, I cannot tell you what I was exposed to
in those 13 months, and this was my job. So for an individual
who is ignorant of the space and things they are invulnerable,
at 20-something, they are not going to have any idea.
Senator Warren. So let me just ask a follow-on question to
that. When servicemembers are headed home, what kind of
information were they given about their exposure and what kind
of risks they might be facing in the future?
Mr. Patterson. It was all self-reporting, that I recall.
Sometimes some units would put something in their medical
record that said, ``You had a burn pit exposure'' or ``You had
a heavy metal exposure from the location that you were in.''
But that was a unit-by-unit situation. Then as mentioned
earlier, they asked this 20-year-old, invincible individuals,
``What were you exposed to?'' ``I'm fine. I don't have any
problems,'' and they move out.
Another concern is then those individuals that never end up
going to the VA at all. You did your tour, you were 22 years
old and bulletproof, and they never went into the VA system.
Then they approach the VA 10 or 20 years later. Now they have
that much of a tougher upstream fight, and the FOB, the
compound names changed constantly. There are some individuals
that probably--you know, that compound no longer existed 5
years later. Quite often they changed every year.
The gentleman talking about being able to link this to an
individual's exposure, unless the personnel operating system
has changed, that unit identification code links everybody to
usually the company level. But if that company operated three
sites, with their platoons broken out to those other sites,
that data is not accurate for that individual. So there are
going to be a lot of challenges, and the further we go back,
the more challenges there are going to be with linking people
to location to exposure.
Senator Warren. Thank you. Thank you very much, Mr.
Patterson.
Mr. Patterson. Thank you, Senator.
Senator Warren. I am going to yield back to the chair.
Thank you very much.
Senator Gillibrand. [Presiding.] Thank you all for your
testimony today. I think you have really informed the committee
what we have to accomplish. I particularly appreciated the
specific requests that you have made of this committee,
specific changes in the law you would like to see. The benefit
of this committee is we are the personnel subcommittee, so we
can write these requirements into law for this year's NDAA. So
you have given us really good information about where the
system is lacking, why it is not getting the data that it
needs, how we actually collect the data we really do need, what
is lacking in terms of when our personnel are getting their
medical exams, and what the baseline is, and what pre-
deployment and post-deployment look like.
I do not know if this was addressed, but did you guys
discuss what is the best way to transfer the medical records
from Active Duty servicemembers to veteran status? What you
would like to see in that transfer of information, and what we
might need to create if we do not have it?
Mr. Porter. Sure, Senator. That should work with the
electronic health record reform. So when that looks right,
which means a seamless transition from the DOD to the VA, and
that that servicemember or veteran can have easy access to that
information.
Senator Gillibrand. And access to the ILER system.
Mr. Porter. Yes, ma'am.
Mrs. Torres. On that point, Senator--sorry, Tom--definitely
consider making ILER accessible to the survivors. I had one
survivor call me and asking assistance in communicating with VA
to access ILER, as she was filing for death benefits, and it
was difficult because ILER did not date back to the time that
he was in service. So lots of challenges there.
Senator Gillibrand. Thank you, and Dr. Szema, you called on
DOD to revamp their method of documentation so that medical
professionals could have better understanding of their
patients' potential exposures. What information would be most
helpful to you to have as you screen and treat patients? What
obstacles do you face with the patients when you are trying to
gather needed information about exposure? Then further, what
training do you think should be provided to medical
professionals so they can better screen and treat their
patients for toxic exposure?
Dr. Szema. We would like to know which region in the
country an individual soldier was in, and what types of
munitions they were exposed to, what the chemical makeup of the
munitions were, how trash was disposed of in that region,
including burn pits, what was in the trash itself, what the
weather patterns were, because of dust storms in the region,
whether depleted uranium was used in that region--for example,
there are armor-piercing rounds, PGU-14, and tank shells with
depleted uranium, as well as even ship ballasts--and whether
that soldier used personal protective equipment. All these
things are important.
Regarding training, in the VA system most compensation and
pension doctors that we have dealt with in the VA are primary
care doctors. They are not pulmonologists, and they are unaware
of burn pit issues, which actually is flabbergasting at this
point in time. But as I mentioned, last month we had a case
where somebody could not go to the War-Related Illness and
Injury Center, which has been an arbiter and an advocate for
us. So they would go to East Orange VA to confirm what we
suspected or wanted a second confirmation of, and one stumbling
block is the local VAs are using it as a hurdle to not get them
benefits.
Senator Gillibrand. Do you think the VAs need to have
pulmonologists on staff?
Dr. Szema. Yes.
Senator Gillibrand. Well, thank you for all your
recommendations. I think this panel has been extremely
effective in laying out a set of requirements and proposal for
how to better address the diseases caused by burn pits and how
to document them through Active Duty, so that when these
individuals become veteran status they have all the information
they need to protect them. Because a lot of these diseases take
5 years, or take 7 years, or take 10 years, depending on the
length of the service of the individual. So we need to have
that information in place, at the ready, so that when they do
go from Active Duty to veteran status it is part of their
record.
We are going to leave this record open for a week, so if
there is any testimony that you think of that you would like to
give, in terms of recommendations, in terms of data,
information, anything else that you want us to have, please
submit it. We are really grateful for your advocacy and your
testimony today. I think it was thorough and extremely helping
in our writing our baseline personnel markup.
Thank you very much. Hearing adjourned.
[Whereupon, at 4:41 p.m., the Committee adjourned.]
[Questions for the record with answers supplied follow:]
Questions Submitted by Senator Kirsten Gillibrand
individual longitudinal exposure record
1. Senator Gillibrand. Dr. Rauch, you testified that the Individual
Longitudinal Exposure Record (ILER) will be fully operable in June
2023. As you develop its capabilities, what challenges are you facing
in ensuring the information included is comprehensive?
Dr. Rauch. One of the challenges we are facing with the information
in ILER assuring that we have identified and accessed all available
exposure monitoring data. Due to the varying austerity of the multiple
deployment locations, some of these locations have more environmental
data than others and are linked to an exposure pathway. One particular
difficulty is that location data are not standardized. Locations are
entered into the Defense Occupational and Environmental Health
Readiness System--Industrial Hygiene as the name of the military base
or geo-coordinates so these need to be validated and quality assurance
approved. The data sources from which ILER is consolidating location
data do not have a standardized data format. All the information needs
to be digested, cross-referenced, and adapted to fit into the ILER data
framework so that it can be displayed in the exposure summaries.
Additionally, receiving individual deployment location data is critical
to linking the servicemember to environmental exposure assessments
completed for his/her location.
2. Senator Gillibrand. Dr. Rauch, what collection gaps will prevent
you from ensuring the data is fully captured?
Dr. Rauch. Some deployment locations have more environmental data
available than others, particularly the larger military bases.
Personal, individual exposure monitoring is a collection gap that the
ongoing Comprehensive Exposure Monitoring Capabilities Based Assessment
is aiming to address. Area monitoring that was conducted at deployment
locations may not be associated with an individual, but can be tied to
a location, thus extrapolation of the data to all servicemembers at the
location is necessary. Declassification of individual deployment
location and classified environmental exposure assessments are
necessary since ILER is an unclassified information technology system.
3. Senator Gillibrand. ly able to access ILER data and when will
servicemembers and veterans be able to directly access their data?
Dr. Rauch. Health care providers, health researchers, and the U.S.
Department of Veterans Affairs (VA) claims adjudicators are able to
access ILER. Servicemembers and veterans are able to access their
respective Individual Exposure Summary through their health care
providers during a medical visit. Per statutory requirement, the VA is
currently working to provide direct access to veterans through the ``My
HealtheVet'' Portal in 2023. The Department of Defense (DOD)
servicemember direct access is in the planning phase.
informing servicemembers
4. Senator Gillibrand. Dr. Rauch, what does the Department of
Defense (DOD) tell servicemembers and their families about the risks of
toxic exposure when they are deployed?
Dr. Rauch. Preventive Medicine threat briefings are provided to
servicemembers prior to deployment. The threat briefings include
information on a wide range of threats, e.g., vector-borne disease,
heat and or cold exposures, water quality, and environmental exposures.
Additionally, servicemembers and their families have direct access to
various DOD-sponsored websites.
5. Senator Gillibrand. Dr. Rauch, what assessments are done when
servicemembers return from deployment to determine whether there was
exposure?
Dr. Rauch. The post-deployment health assessment is conducted
within 30 days of returning from deployment at qualifying locations. A
post-deployment health reassessment is also completed within 90 to 180
days of return from deployment. The deployment-related health
assessments contain a section for documenting occupational and
environmental exposures, including questions on whether the
servicemember was stationed at a location where a burn pit was
operated. The questions in this section on exposure to open burn pits
and other airborne hazards are pursuant to the requirements of Section
704 in the National Defense Authorization Act (NDAA) for Fiscal Year
2020. Pre-and post-deployment blood serum samples are also collected.
An extensive periodic health assessment of all servicemembers is
conducted every year irrespective of deployment status. There are
specific questions about being based or station near open burn pits,
exposure to toxic materials, and enrollment in the Airborne Hazards and
Open Burn Pit Registry.
dod's health response and treatment of exposed servicemembers
6. Senator Gillibrand. Dr. Rauch, other than recordkeeping, what
measures is the Department of Defense currently taking to treat early
onset respiratory illnesses in soldiers exposed to burn pits or toxins?
Dr. Rauch. The DOD is conducting deployment-related health
assessments before and after deployment to assess for any exposure
concerns or onset of respiratory illness. Once a respiratory concern of
illness is identified, an individual is referred to a health care
provider for further evaluation and appropriate medical treatment.
7. Senator Gillibrand. Dr. Rauch, what measures does the Department
of Defense take to detect cancer early when soldiers return from
deployment after burn pit or toxic exposure?
Dr. Rauch. Military personnel have several opportunities to express
concerns about the risk of developing cancer with health care
providers. Screening for cancer without any risk factors, such as age,
family history, or signs or symptoms of cancer, is not recommended by
the American Cancer Society. Most cancers take years to decades develop
and a screening program immediately after return from deployment would
not provide the medical information that a screening program is
designed to provide. Health care providers will weigh the concerns of
the servicemember with the known risk factors before recommending a
cancer screening.
8. Senator Gillibrand. Dr. Rauch, does the Department of Defense
have the proper technology to diagnose and treat respiratory illnesses
and cancers when soldiers return back from deployment where they were
exposed to burn pits or other toxins?
Dr. Rauch. The DOD has trained physicians and other medical
providers to either diagnose and treat respiratory illnesses and
cancers or provide a referral to a specialist when warranted. The DOD
routinely seeks assistance from the wider specialty medical community
whenever a case requires more sophisticated technology or treatments
than is available at the military treatment facility.
sharing information with the department of veterans affairs
9. Senator Gillibrand. Dr. Rauch, how does DOD inform the
Department of Veterans Affairs (VA) that an Active Duty servicemember
has been exposed to airborne hazards, including toxic fumes from burn
pits?
Dr. Rauch. The VA Airborne Hazards and Open Burn Pit Registry
(AHOBPR) captures those DOD servicemembers and veterans that that have
AHOBPR exposures or concerns of exposures that register. Both DOD and
the VA have ongoing outreach and education about the AHOBPR to promote
its use. Servicemembers are encouraged to register if they have any
airborne hazards and burn pit concerns which provides the VA visibility
of servicemember registrants.
Servicemember's ILER exposure summaries are accessible to VA health
care providers, which provide a summary and history of the
servicemember's exposures based on their location. If a servicemember
is determined to have been exposed to burn pit emissions at a deployed
location, a VA health care provider can access the available
environmental health data associated with that exposure.
The DOD Separation Health Physical Examination is performed on all
servicemembers prior to their separation from military service. The
examination includes a section on environmental exposures, including
exposures to burn pits. The completed examination is provided to the
VA, and thus accessible to a VA health care provider if the separated
servicemembers seeks medical care at a VA facility.
training for health care providers
10. Senator Gillibrand. Dr. Mirza, Colonel Newell, Captain Feldman,
in the Fiscal Year 2022 National Defense Authorization Act (NDAA),
Congress required DOD to implement mandatory training for all medical
providers working under DOD on the potential health effects of burn
pits. What type of training do health care providers in each of your
Services currently receive regarding potential effects of burn pits?
Dr. Mirza. The Department of the Army coordinates with the
Department of Veteran Affairs on an annual symposium to exchange
information and train providers on the health effects of airborne
hazards, relevant epidemiological research, the progress of the
Airborne Hazards & Open Burn Pit Registry (AHOBPR), and status of the
implementation of the Individual Longitudinal Exposure Record. The Army
Public Health Center coordinates with the Department of Defense in an
ongoing campaign to educate providers and servicemembers on the
availability and purpose of the AHOBPR and has established asynchronous
online training for providers on the registry available on the
platform, Joint Knowledge Online. The Army trains Occupational &
Environmental Medicine and Preventive Medicine specialists with the
knowledge required to conduct exposure and clinical risk assessments,
medically manage acute casualties from hazardous exposures, and conduct
prospective surveillance of personnel exposed to occupational and
environmental hazards. The Army offers training courses containing
education on environmental hazards available to medical providers,
environmental engineers, industrial hygienists, preventive medicine
technicians, and safety personnel. These courses are available
throughout the year and include, Fundamentals of Occupational Medicine,
Medical Management of Biological and Chemical Casualties, the Army
Public Health Course, and the Military Preventive Medicine Course.
Additional tailored training is offered to preventive medicine
detachments by the Army Public Health Center before their deployment
into a Combatant Command theater. Last, medical school students at the
Uniformed Services University of the Health Sciences attend a 5-day
field training event that prepares them for providing medical care and
responding to environmental exposures in an operational environment.
Colonel Newell. See attachments Tab 2 and Tab 3 in the Appendix.
Per direction of acting ASD, Honorable Mullen, AFMRA prepared a
NOTAM conveying the information within Tab A. It directed all
physicians and privileged providers to accomplish the standardized DHA
training module located on JKO titled ``Airborne Hazards and Open Burn
Pit Registry Overview.'' The training conveyed information and training
for physicians and privileged providers on the health effects of
airborne hazards, relevant epidemiological research, the progress of
the Airborne Hazards & Open Burn Pit Registry (AHOBPR), and status of
the implementation of the Individual Longitudinal Exposure Record.
Captain Feldman. Senator Gillibrand, to support our primary care
providers, the Navy has a variety of specialized health care staff who
are highly-trained and certified to address servicemembers concerns
regarding environmental or toxic exposures such as occupational and
environmental medicine physicians, occupational health nurses,
toxicologists, pulmonologists, family medicine physicians,
environmental health officers, preventive medicine physicians, and
industrial hygienists. They are well-trained and qualified in
comprehensive evaluation and management of occupational and
environmental health concerns and are widely available to address any
exposure-related medical concerns during appointments scheduled
specifically for this purpose at any time, including after deployment.
They are trained in the management of acute and chronic medical
conditions from hazardous exposures, and conduct surveillance of
personnel exposed to occupational and environmental hazards
prospectively, to include operational environments. A history of any
known exposure is also a component of certain medical encounters, such
as occupational medicine examinations.
Additionally, the Defense Health Agency has developed a
comprehensive health care provider focused course on airborne hazards
and open burn pits. The Navy coordinates with the Department of Defense
in an ongoing campaign to educate providers and servicemembers on the
availability and purpose of the Airborne Hazards and Open Burn Pit
Registry (AHOBPR) and has established an accredited asynchronous online
training for providers on the registry available on the platform, Joint
Knowledge Online. The course is titled DHA-US035 Airborne Hazards and
Open Burn Pit Registry Overview.
Through the Airborne Hazards and Open Burn Pit Registry,
servicemembers and veterans can document their potential exposure to
airborne hazards while deployed overseas and are encouraged to
participate in a medical evaluation. For more information about the
registry, or to view and download materials, go to https://
www.Health.mil/AHBurnPitRegistry.
Additional training information and resources are available at the
following: https://www.health.mil/Military-Health-TopicsHealth-
Readiness/Environmental-Exposures/VA-Airborne-Hazards-and-Open-Burn-
Pit-Registry https://www.health. mil/Military-Health-Topics/Health-
Readiness/Environmental-Exposures
11. Senator Gillibrand. Dr. Mirza, Colonel Newell, Captain Feldman,
are there plans to expand that training, and, if so, what information
will be covered?
Dr. Mirza. The Army Public Health Center collaborates with the
Department of Defense to coordinate outreach and education for
providers. While existing training and distributable material are made
available to all providers, current efforts seek to maximize resources
to expand and update training and broaden provider participation.
Recent efforts include several tools to expand training and education.
These include an updated web-based asynchronous course (including the
purpose of the AHOBPR, the registry process, and components of the
medical examination), a Health Care Provider Guide about airborne
hazards, an online Clinical Toolbox, and a to-be-published Memorandum
from the Defense Health Agency Director instructing clinicians in
military medical treatment facilities to receive these tools.
Colonel Newell. As stated, acting ASD, Honorable Mullen directed
that all privileged physicians, nurse practitioners and physician
assistants in primary care, aerospace medicine, occupational health and
medical readiness must complete course DHA-US035 on JKO and view the
Clinical Toolbox by January 31, 2023, and monitor compliance with this
requirement. Future training initiatives by the Defense Health Agency
(DHA) and Airborne Hazards and Open Burn Pit Registry (AHOBPR) Center
for Excellence will be incorporated into annual training requirements
within the AFMS.
Captain Feldman. Yes, the Defense Health Agency has developed and
continues to refine a comprehensive health care provider focused course
on airborne hazards and open burn pits. The training is structured to
provide background to airborne hazards and open burn pits since the
1990s, an introduction to the Airborne Hazards and Open Burn Pit
Registry (AHOBPR), a breakdown to the components of the registry, and a
comprehensive overview of the medical examination for those exposed to
airborne hazards. The training also provides DOD health care providers
a clinical toolbox, resources needed to provide care for those exposed
to burn pits and a comprehensive guide to assist servicemembers who
have been exposed to burn pits. This course explains the registry's
history, eligible deployment dates and locations, and the process
servicemembers and veterans follow to participate in the registry. In
addition, this course will look at why airborne hazards and open burn
pits are of concern and provide references to research on the health
effects of these exposures. This course also describes clinical
considerations for the optional registry medical evaluation and uses
two case studies to enhance learning and interactivity. Upon completing
this course, health care providers will be able to better counsel
servicemembers about the registry and exposure concerns and conduct the
associated medical evaluation. In addition, this course offers numerous
resources for providers to download for future reference. This training
is currently under review to ensure that it meets quality of care and
NDAA requirements. It will be available to all DOD health care
providers online through the Joint Knowledge Online learning management
platform.
health effects of burn pits
12. Senator Gillibrand. Dr. Mirza, Colonel Newell, Captain Feldman,
in the Fiscal Year 2021 NDAA, the Secretary of Defense was required to
provide a briefing to this Committee on DOD's research and studies
conducted on the health effects of burn pits and while it was reported
that studies showed consistent evidence of an association between
exposure to airborne hazards and chronic respiratory symptoms, there
seemed to be a need for more and larger studies to determine more
conclusive findings for respiratory and other diseases. What are the
Department's plans to fund more research in this area?
Dr. Mirza. The Army Public Health Center has led and coordinated
public health studies with the goal of better understanding
servicemembers' health after deployment and exposure to environmental
hazards, including burn pits. The Army Public Health Center resources
these public health studies from its operating budget via the Defense
Health Program authorized by the National Defense Authorization Act.
These public health studies include:
a. Army Public Health Center:
Garshick E, Abraham JH, Baird CP, Ciminera P, Downey G, Falvo MJ,
Hart JE, Jackson DA, Jerrett M, Kuschner W, Helmer D, Jones KD, Silpa
D. Krefft SD, Timothy Mallon T, Miller RF, Morris MJ, Proctor S,
Redlich CA, Cecile Rose C, Rull R, Saers J, Schneiderman AI, Smith NL,
Yiallouros P, Blanc PD. Respiratory health after military service in
Southwest Asia and Afghanistan: An official American Thoracic Society
workshop report. Annals of the American Thoracic Society. 16(8):e1-e16.
2019.
Holley AB, Sobieszczyk M, Perkins M, Cohee BM, Costantoth CB, Mabe
DL,
Liotta R, Abraham JH, Holley, PR, Sherner J. Lung function
abnormalities among servicemembers returning from Iraq or Afghanistan
with respiratory complaints. Respiratory Medicine. 118:84-87. 2016.
Falvo MJ, Abraham JH, Osinubi OY, Klein J, Sotolongo A, Ndirangu
DS, Patrick-DeLuca LA, Helmer DA. Bronchodilator responsiveness and
airflow limitation are associated with deployment length in Iraq and
Afghanistan veterans. Journal of Occupational and Environmental
Medicine. 58(4):325-8. 2016.
Sharkey JM, Abraham JH, Clark LL, Rohrbeck P, Ludwig SL, Hu Z,
Baird, CP. Post-deployment respiratory healthcare encounters following
deployment to Kabul, Afghanistan: A retrospective cohort study.
Military Medicine. 181(3):265-271. 2016.
Sharkey JM and Abraham JH. Evaluation of post-deployment cancers
among active duty military personnel. US Army Medical Department
Journal. 68-75. 2015.
Sharkey JM, Harkins DK, Schickedanz TL, Baird CP. Department of
Defense Participation in the Department of Veterans Affairs Airborne
Hazards and Open Burn Pit Registry: Process, Guidance to Providers, and
Communication. The US Army Medical Department Journal. 2014. July-
September 2014. 44-50. http://www.cs.amedd.army.mil/
FileDownloadpublic.aspx'docid=e358fb9a-c3f2-41d6-93ef-63d352ef3b82
Matthews T, Abraham JH, Zacher LL, Morris MJ. The impact of
deployment on COPD in active duty military personnel. Military
Medicine. 179(11):1273-1278. 2014.
Abraham JH, Clark LL, Sharkey JM, Baird CP. Trends in rates of
chronic obstructive conditions among US military personnel. US Army
Medical Department Journal. p. 33-43. July, 2014.
Abraham JH, Eick-Cost A, Clark LL, Hu Z, Baird CP, DeFraites R,
Tobler SK, Richards, EE, Sharkey JM, Lipnick RJ, Ludwig SL. A
retrospective cohort study of military deployment and post-deployment
medical encounters for respiratory conditions. Military Medicine.
179(5):540-546. 2014.
Abraham JH, Baird CP. A Case-crossover study of ambient particulate
matter and cardiovascular and respiratory medical encounters among
United States military personnel deployed to Southwest Asia. Journal of
Occupational and Environmental Medicine. 54(6):733-739. 2012.
Rose C, Abraham JH. Harkins D, Miller R, Morris M, Zacher L, Meehan
R, Szema A, Tolle J, King M, Jackson D, Lewis J, Stahl A, Lyles MB,
Hodgson M, Teichman R, Salihi W, Matwiyoff G, Meeker G, Mormon S, Bird
K, Baird C. Overview and recommendations for medical screening and
diagnostic evaluation for post-deployment lung disease in returning US
warfighters. Journal of Occupational and Environmental Medicine.
54(6):746-751. 2012.
Abraham JH, DeBakey SF, Reid L, Zhou J, Baird CP. Does deployment
to Iraq and Afghanistan affect respiratory health of United States
military personnel? Journal of Occupational and Environmental Medicine.
54(6):740-745. 2012.
Baird CP, DeBakey SF, Reid L, Hauschild VD, Petruccelli B, Abraham
JH. Respiratory health status of U.S. Army personnel potentially
exposed to smoke from 2003 Al-Mishraq sulfur plant fire. Journal of
Occupational and Environmental Medicine. 54(6):717-723. 2012.
Weese C and Abraham JH. Potential health implications associated
with particulate matter exposure in deployed settings in southwest
Asia. Inhalation Toxicology. 21(4):291-296. 2009.
Airborne Hazards Related to Deployment. Baird, Coleen P., Harkins,
Deanna K., Editors. Borden Institute, Fort Sam Houston, Texas. United
States. Department of the Army. Office of the Surgeon General.
Textbooks of Military Medicine. 2015. Available at https://
medcoe.army.mil/borden-tb-airborne, and including:
Abraham JH, Clark L, Schneiderman A. Epidemiology of airborne
hazards in the deployed environment. In: Textbooks of Military
Medicine: Airborne Hazards Related to Deployment. (Chapter 6) Borden
Institute. 2015. Falls Church, VA 2015.
Abraham JH. Defining health outcomes in epidemiologic
investigations of populations deployed in support of Operations Iraqi
Freedom and Enduring Freedom. In: Textbooks of Military Medicine:
Airborne Hazards Related to Deployment. (Chapter 7) Borden Institute.
2015. Falls Church, VA 2015.
Sharkey J, Baird CP, Eick-Cost A, Clark LL, Hu Z, Ludwig S, Abraham
JH, Clark L, Schneiderman A. Review of epidemiological analyses of
respiratory health outcomes after military deployment to burn pit
locations with respect to feasibility and design issues highlighted by
the Institute of Medicine. In: Textbooks of Military Medicine: Airborne
Hazards Related to Deployment. (Chapter 30) Borden Institute. 2015.
Falls Church, VA 2015.
b. Armed Forces Health Surveillance Division et al.
AFHSD, NHRC, APHC. Epidemiological Studies of Health Outcomes among
Troops Deployed to Burn Pit Sites, May 2010
Colonel Newell. Per USAFSAM, they are not currently engaged in any
discussion or research regarding burn pits at this time.
Captain Feldman. Our Naval Medical Research & Development (NMR&D)
Enterprise support numerous efforts focused on the potential exposures
of Naval Forces to environmental contaminants. While we are dependent
on funding from program sponsors to execute our research activities, we
have continued to maintain a robust portfolio for decades.
Determination of funding amounts and project selection are at the
discretion of the program sponsors.
Within the NMR&D Enterprise, the Environmental Health Effects
Directorate at Naval Medical Research Unit-Dayton studies the potential
health effects related to exposure to chemical stressors (chemicals,
fuels, oils, exhaust fumes, particulate matter) and physical stressors
(temperature, humidity, pressure, noise). The lab is able to evaluate
exposures for virtually any health effect of interest, from memory or
performance related-effects to anxiety, immunosuppression or disease
susceptibility, to reproductive effects and cancers. The Naval Health
Research Center continues to utilize the Millennium Cohort study to
identify novel potential risk factors for diseases and examine whether
environmental contaminants related military deployments could be
associated. Efforts to study environmental contaminants within the Navy
are not only on land, the Naval Submarine Medical Research Laboratory
studies exposure risks in the submarine atmosphere, to include
assessing the use of silicone wristbands as personal environmental
exposure monitors. The lab maintains a database of atmospheric
constituents in this unique environment to enable long-term analysis of
potential effects on submariner health.
__________
Questions Submitted by Senator Mazie K. Hirono
red hill
13. Senator Hirono. Dr. Rauch, I am not sure how familiar you are
with the ongoing crisis at Red Hill. This massive bulk fuel storage
facility has contaminated the Navy's water system--displacing almost
4,000 families since December. As a result, the State of Hawaii has
directed the Navy to defuel the tanks, and DOD will be shutting down
the facility. It seems like DOD has not learned from its past mistakes.
Though not an airborne contamination issue, families who were exposed
to petroleum contaminated water must be treated with the same level of
care, to include tracking long-term effects, as those exposed to toxins
as a result of burn pits. What is DOD doing to prevent these types of
environmental tragedies from occurring in the future?
Dr. Rauch. The DOD conducts extensive routine assessments of all
operations to assure required environmental compliance, hazardous
material management, and system safety procedures are in place to
prevent accidental releases of hazardous substances. Deficiencies
identified during the assessments are prioritized for mitigation and
repair. Various actions are implemented during the mitigation and
repair process to assure individuals are not exposed to any hazardous
substances. In addition, we learn from each occurrence to apply lessons
and try to proactively prevent them in the future.
14. Senator Hirono. Dr. Rauch, what has DOD done as far as
establishing procedures to help track and address petroleum exposures,
and other contaminants, among servicemembers and their families?
Dr. Rauch. An official record of the potentially exposed population
was established as an Incident Report (IR) (# 894583) in the Defense
Occupational and Environmental Health Readiness System (DOEHRS). This
DOEHRS IR was created to collect names of individuals potentially
exposed to contaminated drinking water from the Navy distribution
system at Joint Base Pearl Harbor-Hickam. There are currently over
24,000 individuals in the IR. DOEHRS is the DOD system of record for
entering, assessing, managing and reporting occupational and
environmental exposures for DOD personnel, and has been expanded in
this case to include family members as well. The data will be retained
in DOEHRS for a minimum of 30 years, and is available for any future
action, research or analysis. The DOD public health enterprise intends
to use the IR as a roster for assisting in conducting future health
surveillance, as indicated.
There has been significant interagency collaboration between
Department of the Navy, the Agency for Toxic Substances and Registry
(ATSDR) and Hawaii DOH. ATSDR conducted a web-based health survey for
Hawaii DOH open to all potentially affected individuals who received
water from the Navy water distribution system. The ATSDR survey was
completed on 7 Feb 2022. On February 16, 2022 a preliminary
presentation of the results of the survey was provided. The survey
included 2,314 participants on the Navy water distribution system, 88
percent of whom identified as DOD-affiliated. To date and based on
available data, ATSDR has not recommend that Hawaii DOH establish a
health registry at this time and recommended a 6-month followup survey
with continued collaboration with Hawaii DOH.
15. Senator Hirono. Dr. Rauch, how will DOD use electronic health
records integration, in conjunction with the VA, to ensure that
potential exposures are being tracked during service and that that
information is going with a servicemember when they transition out, to
include retirees who continue to access healthcare via Tricare?
Dr. Rauch. At full functionality, the ILER will be interoperable
with the EHR. Servicemembers' ILER exposure summaries are accessible to
VA health care providers, which provide a summary and history of the
servicemember's exposures based on their location. If a servicemember
is determined to have been exposed to burn pit emissions at a deployed
location, a VA healthcare provider can access the available
environmental health data associated with that exposure. Additionally,
the DOD and VA are working toward an interoperable EHR that will allow
a servicemember separating from Service continue to receive continuity
of care through the VA.
burn pit registries
16. Senator Hirono. Dr. Rauch, what is DOD doing to ensure
servicemembers know about the registry and sign up?
Dr. Rauch. The DOD, in collaboration with the VA, are engaged in an
extensive ongoing education and outreach campaign to spread awareness
and information about the registry and eligibility. The DOD and VA have
reached out to potentially eligible servicemembers directly through
physical mailers, social media, and outreach on leave and earnings
statements. Servicemembers are made aware of the Registry on the post-
deployment and post-deployment health reassessments, as well.
17. Senator Hirono. Dr. Rauch, how does DOD track exposures for
those who don't opt-in?
Dr. Rauch. It is DOD policy to conduct routine deployment health
assessments before, during, and after deployments to track exposures
and manage health risks from potentially hazardous occupational or
environmental exposures. The health assessments become part of
servicemembers' medical record and is available via the servicemember's
individual exposures summaries within in ILER. These practices are
standard regardless of whether an enrollment status in the AHOBPR.
18. Senator Hirono. Dr. Rauch, what is DOD's long-term plan to
accommodate medical care for those exposures?
Dr. Rauch. The DOD provides complete medical care for all
servicemembers prior to their separation. Retired servicemembers are
eligible for continued medical care through the TRICARE benefit.
Similarly, the VA provides complete medical care for eligible
servicemembers upon separation. For service-connected medical
conditions, the VA will continue to provide medical care.
19. Senator Hirono. Dr. Rauch, are Tricare providers trained to be
attentive to conditions that are associated with burn pit exposure?
Dr. Rauch. The DOD and VA are providing training to providers on
airborne hazards and burn pit exposures.
The DOD and VA will assess opportunities to make this training
available to TRICARE providers.
areas for future attention
20. Senator Hirono. Dr. Szema, Mr. Porter, Mrs. Torres, Mr.
Patterson, in your opinion, what other unheard or underfunded military
health concerns associated with the work environment need to be
identified and addressed?
Dr. Szema. There are three themes regarding unexplored, unheard, or
underfunded military health concerns associated with the work
environment that need to be identified and addressed.
1. Remote Biometric Monitoring
2. Environmental Metrics
3. New candidate drugs
Firstly, as you continue to explore methods of funding in this
area, we request that you consider the opportunities that Remote
Biometric Monitoring may offer these soldiers. We have been working
together for several years with Play-it Health Company in Kansas since
2019 to provide remote monitoring to our patients. We were able to
augment care acutely to our patient population during the onset of the
COVID pandemic in March 2020 when access to in-person contact was
limited; we had significant improvement in outcomes. A manuscript is
under review for publication. We have used Bluetooth continuous pulse
oximeter ring devices to wear on fingers and have handheld Bluetooth
spirometers to measure lung function.
Several years ago, we applied unsuccessfully to the NIH with
pulmonologist Elizabeth Tam, MD, at the University of Hawaii, for a
grant to do wristband remote monitoring of particulate matter exposure
for Hawaiians exposed to wildfires. I was there in Maui on the highway
when the fire approached Oprah's house and my family evacuated to
Kauai.
Secondly, now with United States soldiers on the eastern European/
Ukraine front and the threat of chemical and biological weapons from
Russia, and pandemic-related infections worldwide is real, similar
monitoring of temperature for fever, oxygen saturation, heart rate,
plus additional Environmental Metrics such as particulate matter
exposure, sarin gas, and direction of gunshots is critical. I applied
for a Congressionally Directed Medical Research Grant with the
Cornerstone Research Group (CRG) in Ohio to develop a wearable device
on a soldier's belt. It would measure particulate matter concentration
exposure, sarin gas levels, and gunshot sounds, We got a good score
(outstanding 1.3) but were told that the DOD does not have sufficient
funding for burn pits even though the request for applications was for
burn pits research. GRANT ID GRANT13460409 CDMRP LOG PR21113.
We are now launching projects to explore remote biometric
monitoring in these burn pit victims. We have noted that standard
monitoring, which usually involves static measurements at rest in
clinics, likely misses significant components of the dysfunction these
patients experience. We are working with patients to better document
their biometrics with symptoms and activity, to lend more insight into
better methods of treatment and rehabilitation.
We believe that providing funding to monitor these patients more
closely would be very beneficial and that the findings will also be
generalizable to other groups, such as those experiencing Long COVID.
Thirdly, we have already published a mouse model of burn pit lung
injury (both Iraq and Afghanistan) and have 9/11 dust to make a model
of World Trade Center Lung Injury. We have tested candidate drugs and
have coinvented potent New Candidate Drugs. However, the next stage in
startup drug development for my company RDS2 Solutions, Inc.
(RDS2solutions.com) requires $2.5 million to send these candidate
compounds to so-called GMP labs to test in several species of animals
for toxicology (safety), pharmacokinetics (time course of drug
absorption, distribution, excretion, metabolism) and pharmacodynamics
(intensity of drug effect in relation to concentration). Then, a report
can be submitted to the FDA for an investigational new drug (IND) to
test in humans. This is costly and not funded with academic grants. So,
funding from the DOD would allow us to tailor a drug specifically for
burn pit and war airborne hazards lung injury.
Mr. Porter. I don't have any underfunded DOD matters, but I do have
top priority VA concerns I am happy to discuss with her staff, but I
know that is not within the SASC jurisdiction. If they would like to
discuss that I am happy to.
Mr. Patterson. Deployed environmental health surveillance, as a
whole, is underfunded and under prioritized within the DOD. A review of
our progress in this space since Desert Storm shows rather limited
advancements when compared to many other areas of military medicine,
weapons, or equipment.
Creation of a small, light, wearable sensor for environmental
exposures needs funding. The DOD needs to look at new and unique
solutions in this space to push the science forward for an individual
monitor. Ideally, it would provide near real time information to the
individual and/or to senior leaders who can address exposures as
needed.
Better, deployable area monitors/sensors also need to be developed.
Drone based options for deployment or air droppable units which could
be sent in prior to entry of U.S. personnel would also be valuable
options.
Remote sensing for environmental exposures needs to be funded so
that small teams or unique releases may be tracked in future
operations.
The synergistic effects and outcomes of multiple exposures is an
area which is not well understood. However, the variables there are
significant and the potential combinations would create a very large
challenge to evaluate. With 50,000+ toxic industrial chemicals and
materials which could be mixed in many ways one can see the challenge
there.
This is why I would suggest looking at the biomarkers which are
changed during a servicemember's deployment or over their career due to
environmental exposures. This could also allow for improved treatment
of people if their individual exposure can be defined. It could also
allow us to rule out certain exposures which would improve treatment as
well as bringing some people peace of mind if they could be shown that
suspected exposures did not occur to them.
Allow for easier testing of people who think they have been exposed
to certain substances. This could put many people's mind at ease if
they are found to have not been exposed and allow for more efficient
treatment of people if the testing shows that they did have an
exposure.
The combustion products created by the burn pits is not well
understood. Some studies have been conducted in this space. However,
they were not done as a burn pit in a deployment is actually operated
which will impact what is created. A larger concern though is that the
studies did not include the lithium batteries, pressure treated lumber
(often with arsenic or formaldehyde), galvanized metal, nor the
quantities of plastic which were typical.
A study needs to be conducted as to why, in a mature theater of
operations, the DOD relied so heavily on bottled water shipped into the
theater. This resulted in millions of plastics bottles being burned
which added to those potential exposures from the burn pits. A second
concern is if the DOD has the ability to provide safe water on the
battlefield of the future when logistics may prevent the massive
shipment of water onto and around the battlefield. One must be
confident that the water they are producing in bulk on a future
battlefield isn't creating an environmental exposure for those
servicemembers.
Review policy and doctrine and have the risks of environmental
exposures included in them as a factor in future decision-making
processes.
__________
Questions Submitted by Senator Thom Tillis
burn pits
21. Senator Tillis. Dr. Rauch, the VA has estimated that 3.5
million servicemembers have been exposed to toxic materials from burn
pits over the past 20 years. Does this number reflect DOD records?
Dr. Rauch. Yes, approximately 3.5 million servicemembers have been
exposed to airborne hazards, specifically fine particulates, which
include organic and inorganic dusts, diesel generator and vehicle
emissions, automobile and industrial pollutants. A subset of these
servicemembers include those exposed to burn pits, which also generate
particulates.
22. Senator Tillis. Dr. Rauch, what are known locations of existing
burn pits?
Dr. Rauch. Syria, Yemen, Iraq, Egypt, and Chad.
23. Senator Tillis. Dr. Rauch, what are the sizes/dimensions of
existing burn pits?
Dr. Rauch. Currently, the size or dimensions of each burn pit are
not available.
24. Senator Tillis. Dr. Rauch, how many servicemembers are
stationed at the locations of the existing burn pits? Please speak to
the record keeping and tracking of these servicemembers in proximity to
burn pits currently in use.
Dr. Rauch. As of April 15, 2022, the DOD is aware of seven active
burn pits being operated by host nations or allies proximate to where
U.S. Forces are stationed. These locations are:
a. Syria (2 locations, approximately 234 and 249 United States
Personnel);
i. 300 and 800 meters away from work/sleep areas
ii. Periodic occupational and environmental health sampling and
assessments are conducted.
b. Yemen (approximately 150 United States personnel);
i. 3,000 meters away from work/sleep areas
ii. Occupational and environmental health sampling and
assessments are conducted.
c. Iraq (approximately 50 United States personnel);
i. 3,000 meters away
ii. Occupational and environmental health sampling and
assessments are conducted.
d. Egypt (approximately 93 United States personnel);
i. 1,000 meters away
ii. Occupational and environmental health sampling and
assessments are conducted.
e. Chad (2 Burn pits; approximately 60 United States personnel)
i. 1000 meters and 700 meters away from common living spaces
ii. Occupational and environmental health sampling and
assessments are conducted.
25. Senator Tillis. Dr. Rauch, what are suspected/unconfirmed
locations of burn pits? Please speak to the types of waste being
disposed of at these burn pits and any mitigation efforts in use to
limit exposure and risk to troops in proximity.
Dr. Rauch.
A. A list of unconfirmed locations is not available.
B. Only non-hazardous and non-infectious solid waste is being
disposed and burned in active burn pits
C. Mitigation efforts include moving the pits further away from
personnel to 2,000 meters from perimeter of base/camp and prominent
down wind direction, conducting quarterly site assessments,
establishing personal protective equipment use and training as needed,
conducting OEH sampling, limiting burn pit use; replacing the burn pits
with dumpsters or incinerators, hauling waste away in place of burning,
and assessing health risks.
26. Senator Tillis. Dr. Rauch, please provide environmental reports
associated with the existing burn pit locations, as well as
confirmation that the environmental reports have been added to the
Individual Longitudinal Exposure Record (ILER) system.
Dr. Rauch. ILER system provides environmental health risk
assessments for populations. The environmental reports (such as OEHSAs,
Base Camp Assessments, and various surveys) provide a foundation of
information to assist with identification and prioritization of
potential health threats to the deployed population. Those potential
threats are assessed to generate an estimate of the health risk to the
servicemembers. The health risk estimate reports (or health risk
assessments (HRAs)) are uploaded into the DOD system of record
(DOEHRS), and ILER imports those HRAs. The ILER also pulls the Periodic
Occupational and Environmental Monitoring Summaries that are completed
periodically to summarize all occupational and environmental health
risks to the population at a deployed location.
Health Risk Assessment Reports (HRAs) have been completed for both
Syria locations and North Camp, Egypt. Yemen also has an HRA currently
in progress. DOD will follow the operations security process required
to release HRAs outside of DOD.
27. Senator Tillis. Dr. Rauch, please provide the Committee with a
copy of the pre/post deployment health assessments that are issued to
each servicemember.
Dr. Rauch. Current pre deployment health assessment, post
deployment health assessments, post deployment health re-assessments,
and periodic health assessment (Page 4) are attached. Please see the
appendix for this information.
__________
Questions Submitted by Senator Josh Hawley
airborne hazards
28. Senator Hawley. Dr. Rauch, what is DOD's estimate for the
number of individuals who would qualify for the presumption of service-
related connection, given how many individuals were likely exposed
since 2001?
Dr. Rauch. Thus far, VA has established three presumptions for
asthma, rhinitis, and sinusitis related to fine particulate matter,
along with nine rare respiratory cancers. At present it is unknown how
many individuals (veterans) would qualify for one of these
presumptions. Additional analysis in coordination with the VA is
required to provide an answer to the question.
Appendix
Supporting documents for Colonel Newell question #10.
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Supporting documents for Dr. Rauch question #27.
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